RQIA Enforcement Procedures

(Document 2 in a Suite of 6)

Effective From: April 2017

Date of Issue: April 2017

Date of Review: April 2019

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Contents Page

Definitions and Abbreviations 3

1. Introduction 5

2. Principles 5

3. The Legislative Framework 5 Unregistered Establishment or Agency 6

4. Enforcement Process 6 Enforcement Actions 7 Issuing and Serving Enforcement Documents 8 Communication with Stakeholders 9

5. Enforcement Decision Making (EDM) 9

6. Serious Concerns (SC) 10 Serious Concerns - Meeting Preparation 10 Serious Concerns - Meeting 10 Non-Attendance 11 Serious Concerns - Meeting Outcomes 11

7. Improvement Notice (IN) 11 Intention to Serve an Improvement Notice - Meeting

Preparation 12

Intention to Serve an Improvement Notice - Meeting 12 Non-Attendance 13 Not Serving an Improvement Notice 13 Serving an Improvement Notice 13 Compliance Assessment 14 Compliance Achieved 14 Compliance Not Achieved 15

Enforcement Relating to Part III Establishment and Agencies Only 16

8. Failure to Comply Notice (FTC) 16 Intention to Serve a Failure to Comply Notice - Meeting

Preparation 16

Intention to Serve a Failure to Comply Notice - Meeting 17 Non-Attendance 17 Not Serving a Failure to Comply Notice 18 Serving a Failure to Comply Notice 18 Compliance Assessment 19 Compliance Achieved 19 Compliance Not Achieved 19

9. Notice of Proposal (NOP) 20 Intention to Serve a Notice of Proposal - Meeting Preparation 21 Intention to Serve a Notice of Proposal - Meeting 21 Non-Attendance 22 Not Serving a Notice of Proposal 22 Serving a Notice of Proposal 22 Representation 23 Not Adopting a Proposal 23

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10. Notice of Decision (NOD) 24 Serving a Notice of Decision 25 Appeal to the Care Tribunal 25 When does RQIA’s Decision Take Effect? 26 Removal or Variation of Imposed Conditions 27

11. Urgent Procedure 27 Appeal to the Care Tribunal 29

12. Other Actions RQIA May Take in Respect to Services Not Falling Under Part III of the 2003 Order

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List of Appendices

Appendix 1 RQIA’s Stakeholders

Appendix 2 RQIA’s Quality Improvement Plan

Appendix 3 Associated Templates

3.1 Unregistered Establishments or Agencies Templates 3.2 Serious Concerns Templates 3.3 Improvement Notices Templates 3.4 Failure to Comply Templates 3.5 Notice of Proposal Templates 3.6 Notice of Decision Templates 3.7 Urgent Procedure Templates

Appendix 4 Enforcement Process Flow Charts

4.1 Enforcement Decision Making Procedure 4.2 Serious Concerns Procedure 4.3 Improvement Notice Procedure

4.3.1 Extension Improvement Notice Procedure 4.4 Failure to Comply Procedures

4.4.1 Extension Failure to Comply Procedure 4.5 Notice of Proposal and Notice of Decision Procedure to Cancel

Registration 4.6 Notice of Proposal and Notice of Decision to Refuse an

Application for Registration 4.7 Notice of Proposal and Notice of Decision Procedure to Grant

an Application Subject to any Conditions Not Agreed in Writing, To Vary or Remove any Condition, To Impose Any Additional Condition on Registration

4.8 Urgent Procedure

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Definitions and Abbreviations RQIA – Regulation and Quality Improvement Authority. DHSSPS – Department of Health and Social Services and Public Safety, now called Department of Health (DoH). DoH – Department of Health, which is the new name for the DHSSPS. 2003 Order – The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, which is the legislation that sets out RQIA’s statutory responsibilities and powers. Regulations – created by the DHSSPS (now known as the DoH), these documents specify the regulations that each type of establishment or agency must operate within. Standards – prepared and published by the DHSSPS (now known as the DoH), these documents identify the acceptable minimum standard for each type of establishment or agency. QIP – Quality Improvement Plan is a section within the inspection report that states all areas for compliance with regulations and/or standards. The Registered Person/Trust’s Responsible Individual is required to complete the QIP, setting out the actions taken/to be taken in accordance with timescales determined by RQIA. Registered Manager – individual registered with RQIA to manage an establishment or agency. Registered Provider – an individual, an individual in partnership with others, a partnership or an organisation registered to carry on an establishment or agency. Registered Person/s – the Registered Provider or the Registered Manager in respect of an establishment or agency. Responsible Individual – an individual e.g. a director, a manager, a secretary, or other officer of an organisation, who is responsible for supervising the management of an establishment or agency. Trust’s Responsible Individual – the Chief Executive in respect of a trust. EDM – An internal ‘Enforcement Decision Making’ meeting that takes place at key decision stages within RQIA’s enforcement procedure. IN – an ‘Improvement Notice’ which may be served when there have been failings to comply with minimum standards. FTC – a ‘Failure to Comply Notice’, which may be served against failings to comply with regulations.

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NOP – a ‘Notice of Proposal’ may be served when RQIA are proposing to refuse an application, cancel registration, vary, remove, or impose conditions on registration. NOD – a ‘Notice of Decision’ may be served if RQIA have not received or upheld representations regarding a NOP within the specified timescale. ERP – An internal ‘Enforcement Review Panel’ meeting may be convened to consider any representations made to RQIA’s Chief Executive Officer (CEO) in respect of Improvement Notice/s or Failure to Comply Notice/s. See ‘RQIA Enforcement Review Panel (ERP) Procedures in Respect of Improvement Notice/s’ and ‘RQIA Enforcement Review Panel (ERP) Procedures in Respect of Failure to Comply Notice/s’ for more information. DMP – An internal ‘Decision Making Panel’ meeting may be convened to consider any representation made to RQIA’s CEO in respect of Notice/s of Proposal. When RQIA has issued a NOP to refuse or cancel registration of an establishment or agency, a DMP will always be convened. A DMP will also always be convened:

when RQIA wish to make an application to a Lay Magistrate for an order using urgent procedures

when representation is received regarding a NOP to vary, remove or impose an additional condition

See ‘RQIA’s Decision Making Panel (DMP) Procedures in Respect of Notice/s of Proposal’ and ‘RQIA’s Decision Making Panel (DMP) Procedures in Respect of Urgent Procedures’ for more information.

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1. Introduction

1.1. These procedures should be read as part of a suite of documents regarding enforcement action taken by RQIA that includes:

RQIA Enforcement Policy (Document 1 in a Suite of 6)

RQIA Enforcement Review Panel Procedures in Respect of Written Representation Regarding Improvement Notice/s (Document 3 in a Suite of 6)

RQIA Enforcement Review Panel Procedures in Respect of Written Representation Regarding Failure to Comply Notice/s (Document 4 in a Suite of 6)

RQIA Decision Making Panel Procedures in Respect of Notices of Proposal (Document 5 in a Suite of 6)

RQIA Decision Making Panel Procedures in Respect of Urgent Procedures (Document 6 in a Suite of 6)

1.2. These procedures should be read in conjunction with other relevant RQIA

policies and procedures. A suite of templates has been developed for guidance purposes only.

2. Principles

2.1. Enforcement activity taken by RQIA will be in line with RQIA’s Enforcement Policy and the principles of good regulation outlined by the Better Regulation Task Force (Principles of Good Regulation), Cabinet Office Publication, (October 2003) and Regulators’ Code, Better Regulation Delivery Office (April 2014).

3. The Legislative Framework

3.1. In accordance with Article 12 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (2003 Order), any person who carries on or manages an establishment or agency without being registered under Part III of the 2003 Order shall be guilty of an offence.

3.2. All registered establishments and agencies are required to comply with the 2003 Order and the relevant regulations. The 2003 Order and the associated regulations are available on RQIA’s website.

3.3. Registered Person/Trust’s Responsible Individual/s are required to ensure that their establishment/agency/trust provide a standard of care and service in accordance with the Department of Health, Social Services and Public Safety (DHSSPS) standards. A list of relevant standards is available on RQIA’s website.

3.4. RQIA may take a range of enforcement actions at the same time, provided each action clearly identifies the separate failures to comply with regulations and/or standards.

3.5. RQIA may seek to prosecute in conjunction with other enforcement actions.

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3.6. RQIA retains the right to seek legal opinion at any point within the enforcement process. Unregistered Establishment or Agency

3.7. Where RQIA becomes aware of the existence of an unregistered establishment or agency, the relevant inspector/s will carry out an initial investigation to clarify the nature of the service provided, and determine whether an offence is being committed. The inspector/s will provide an update to the Head of Programme who will inform the Director of Regulation and Nursing. If it is determined that an offence is being committed, RQIA’s CEO will be informed. Please see RQIA’s Prosecution Procedures.

3.8. Following a review of the circumstances and consideration of available evidence and receipt of an acceptable application, RQIA may decide that it may be appropriate to proceed with the registration of the establishment or agency providing that relevant satisfactory safeguards for service users are in place until registration is granted. The Director of Regulation and Nursing will confirm this decision in writing to the person carrying on or managing the establishment or agency, including any contingency plans agreed pending registration, to ensure the safety and welfare of service users (appendix 3, template UR1). If the person carrying on or managing the establishment or agency fails to comply with the agreed undertakings then RQIA may take a range of enforcement actions, see paragraph 3.4. Please see RQIA’s Prosecution Procedures.

3.9. RQIA has the authority to write to a person who is believed to be carrying on or managing an establishment or agency without being registered to require them to cease operation and to confirm the implications of continuing to provide an unregistered establishment or agency (appendix 3, template UR2).

3.10. All relevant stakeholders will be informed of the outcome of RQIA’s assessment of the unregistered status of the establishment or agency and if appropriate its view that an offence is being committed (appendix 1 – list of stakeholders).

4. Enforcement Process

4.1. In line with the principles set out in the RQIA Enforcement Policy, and throughout this document, RQIA will normally adopt a stepped approach to enforcement.

4.2. It is the Registered Person/Trust’s Responsible Individual’s responsibility to fully understand that the regulations and standards form the basis of the regulatory framework and that these should be complied with. Reference might be made to best practice and codes of practice by inspectors.

4.3. Staff involved in enforcement activity should ensure that all records held are robust, provide clear evidence of decision making and adhere to relevant RQIA’s policies and procedures.

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4.4. In line with RQIA’s Inspection Procedures, inspector/s will provide feedback to the Registered Person/Trust’s Responsible Individual/s at the end of the inspection on the inspection outcomes and any areas of improvement will be identified with clear timescales.

4.5. Failing to comply with a minimum standard may also be linked to a failure to comply with a regulation. Any such failure will be set out in the inspection report and the Registered Person/s must act on these to ensure compliance with the 2003 Order, relevant regulations or a condition of registration.

4.6. The Registered Person/Trust’s Responsible Individual/s will be required to complete the Quality Improvement Plan (QIP) detailing how areas of concern are to be addressed. The QIP will be submitted by the Registered Person/Trust’s Responsible Individual/s for review by the inspector to ensure that the proposed action is sufficient to achieve compliance within the identified timescales (appendix 2 – QIP).

4.7. If a failure to comply with a specific standard and/or regulation has been stated for the second time in an inspection report and an inspector identifies that it has not been addressed or compliance has not been sustained, an EDM meeting must take place. Only in exceptional circumstances should a specific failure to comply with a regulation or standard be stated for a third time. Where this is the case, a full explanation should be noted by the inspector within the EDM meeting record. Enforcement Actions

4.8. Where an inspector identifies an establishment/agency/trust, which is failing to comply with regulations or failing to comply with any statement of minimum standards, RQIA will consider the various options to enable that establishment/agency/trust to secure compliance. Depending on the circumstances and an assessment of the associated risks and the response from the Registered Person/Trust’s Responsible Individual/s, RQIA will consider a range of actions. This may include providing advice and guidance, and/or applying one or more of the following actions. For all establishments/agencies/trusts RQIA may:

highlight failings to comply with minimum standards and regulations

hold a Serious Concerns Meeting

hold an Intention to Serve an Improvement Notice Meeting

serve an Improvement Notice For establishments or agencies registered or falling to be registered under Part III of the 2003 Order, RQIA may:

hold an Intention to Serve a Failure to Comply Notice Meeting

serve a Failure to Comply Notice

hold an Intention to Serve a Notice of Proposal Meeting

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serve a Notice of Proposal to: o grant an application subject to any conditions not agreed in writing

between RQIA and the applicant o refuse an application to register an establishment or agency o cancel registration of an establishment or agency o vary or remove any condition in force in relation to the registration of

the establishment or agency o impose any additional condition in relation to the registration of an

establishment or agency o refuse an application of a Registered Person under Article 16 of the

2003 Order for the variation or removal of a condition relating to registration

serve a Notice of Decision to adopt a proposal

use urgent procedures to apply for an order to cancel registration, vary, remove or impose conditions on registration.

4.9. Enforcement action may be escalated at any time. This will be proportionate

and related to the level of risk to service users and the seriousness of any failure to comply with minimum standards and/or any breach of regulation. RQIA will follow up enforcement action to ensure that quality improvements are achieved.

4.10. In circumstances where RQIA has serious concerns about a service user’s life, health or wellbeing, RQIA may use urgent procedures to cancel the registration of an establishment or agency or that of a Registered Person.

4.11. RQIA may increase inspection activity for a period of time to monitor compliance and to ensure the necessary improvements are being made and maintained. Issuing and Serving of Enforcement Documents

4.12. A notice is deemed issued on the same date it leaves RQIA and this will be clearly marked on the notice. Where a notice has been served to advise of an extended compliance date, the new notice will also contain the original date of issue.

4.13. Where applicable, notice/s and accompanying letters will be sent by special delivery post to the Registered Person/Trust’s Responsible Individual’s address as it appears on RQIA’s register or an alternative address nominated by the Registered Person/Trust’s Responsible Individual/s, and is deemed served the next working day. Notice/s can be hand delivered (e.g. by courier or an RQIA representative). If the notice/s are hand delivered, a record to confirm delivery should be obtained (appendix 3, templates IN12, FTC12, NOP10, NOD3) and held on the relevant file and the notice is deemed served on the date it is signed for. Where the Registered Person/Trust’s Responsible Individual/s has provided RQIA with their email address, password protected enforcement documents can also be forwarded by email.

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4.14. Under the Urgent Procedures, an order and covering letter will be sent by special delivery post to the Registered Person’s address as it appears on RQIA’s register or alternative address nominated by the Registered Person/s and is deemed served the next working day. The order can be hand delivered (e.g. by courier or RQIA representative) to the Registered Person’s address as it appears on RQIA’s register or alternative address nominated by the Registered Person/s. If the order is hand delivered, a record to confirm delivery should be obtained (appendix 3, template UP2) and held on the relevant file and the order is deemed served on the date it is signed for.

4.15. All other enforcement documents issued by RQIA will be sent by special delivery to the Registered Person/Trust’s Responsible Individual/s as it appears on RQIA’s register or alternative address nominated by the Registered Person/Trust’s Responsible Individual/s. On some occasions, rather than posting, it may be necessary to hand deliver items to the Registered Person/Trust’s Responsible Individual/s. A record of this will be made (appendix 3, template UR3 and SC5). Where the Registered Person/Trust’s Responsible Individual/s has provided RQIA with their email address, the enforcement documents can also be forwarded by password protected email.

4.16. If it comes to the attention of RQIA that a clerical error appears in a served notice, RQIA will reissue a corrected notice as quickly as possible (appendix 3, templates IN8, FTC8, NOP8, NOD4). The date of issue and compliance date will remain the same. Communication with Stakeholders

4.17. RQIA decisions to take enforcement action may have specific consequences for service users and other stakeholders. RQIA should always consider:

which stakeholders need to be informed;

the appropriate method of communication, and

what, when and with whom information should be shared throughout the different stages of this enforcement procedure.

4.18. RQIA will consider whether the noncompliance with minimum standards

and/or breach of regulations constitutes a possible breach of professional codes of practice. Where it is deemed appropriate, RQIA will make a referral to the relevant professional regulator.

4.19. In line with the 2003 Order, RQIA’s CEO will inform the Department of Health about the quality of health and social care services, including any actions taken under RQIA’s Enforcement Policy and Procedures.

5. Enforcement Decision Making (EDM) (Appendix 4 – Chart 1)

5.1. EDM meetings will be scheduled as required throughout the enforcement process at any key decision point.

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5.2. An EDM meeting provides an opportunity for RQIA’s inspectors and senior management to discuss issues of concern. Decisions taken at the meeting will be risk based and proportionate. A record of this meeting detailing the rationale and outcomes arising from it is maintained.

5.3. Timescales for the EDM meeting are dependent on the issues identified and the level of risk.

5.4. The inspector should prepare the relevant information and consider enforcement options proportionate to the issues/risks identified. Where appropriate the meeting will take account of the number of times areas of improvement/recommendations/requirements have been stated, and any actions taken by the Registered Person/Trust’s Responsible Individual/s.

5.5. The EDM meeting will be chaired by the Senior Inspector/HOP/relevant Director/CEO. The inspector/Senior Inspector should present the relevant information for discussion and options will be considered.

6. Serious Concerns (SC) (Appendix 4 – Chart 2)

6.1. As a result of an EDM meeting and the level of risk to service users identified, a decision to hold a SC meeting might be made.

6.2. The SC meeting should take place as soon as is practicable. Serious Concerns - Meeting Preparation

6.3. A letter of invitation to meet the Head of Programme/Senior Inspector and/or relevant inspector/s will be issued to the Registered Person/Trust’s Responsible Individual/s from the Head of Programme (appendix 3, template SC1).

6.4. Contact with the Registered Person/Trust’s Responsible Individual/s may also be made by telephone and followed up in a letter. A record of the telephone call will be retained.

6.5. In the event that a Registered Person/Trust’s Responsible Individual indicates they or an appropriate representative cannot attend on the date given in the invitation letter, the meeting may be rescheduled. The Registered Person/Trust’s Responsible Individual will be notified (appendix 3, template SC2). Serious Concerns - Meeting

6.6. The purpose of the SC meeting is to:

discuss with the Registered Person/Trust’s Responsible Individual/s RQIA’s concerns about the precise nature of the areas of potential noncompliance;

agree the required action/s that must be taken to ensure compliance/quality improvement;

agree the timescale within which any remedial action must be taken; and

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advise the Registered Person/Trust’s Responsible Individual/s of RQIA’s stepped approach to enforcement should compliance not be achieved.

6.7. A note of the SC meeting will be taken and will include any decisions made

and actions agreed. Non-Attendance

6.8. In the event of non-attendance of the Registered Person/Trust’s Responsible Individual/s or their nominated representative to the SC meeting, information will be sought to establish the reason for non-attendance. An EDM meeting will be convened during which the Head of Programme and relevant inspector/s will discuss and agree the next steps to be taken. A record of all attempts to contact the Registered Person/Trust’s Responsible Individual/s by telephone/email must be retained, including the content of any subsequent discussion. If a valid reason for non-attendance is established, a decision may be made to reschedule the meeting. The Registered Person/Trust’s Responsible Individual/s will be notified (appendix 3, template SC2). Non-attendance without due reason may result in an escalation of enforcement action.

6.9. A letter confirming the decisions made and any actions agreed will be forwarded to the Registered Person/Trust’s Responsible Individual/s as soon as practicable after the EDM meeting (appendix 3, template SC3). Serious Concerns - Meeting Outcomes

6.10. A letter detailing the outcomes of the SC meeting will be issued to the Registered Person/Trust’s Responsible Individual/s following the meeting (appendix 3, template SC4).

6.11. Following the issue of the letter (appendix 3, template SC4) the inspector/s will monitor and review the Registered Person/Trust’s Responsible Individual’s compliance with the actions agreed, as appropriate. In these circumstances, it may also be necessary to increase inspection activity to encourage and support improvements in the establishment/agency/trust.

7. Improvement Notice (IN) (Appendix 4 – Chart 3 and 3a)

7.1. Article 39 of the 2003 Order makes provisions that RQIA may serve an IN, if the Registered Person/s, Regional Health and Social Care Board (RHSCB), Health and Social Care Trust (HSC trust) or special agency is failing to comply with any statement of DHSSPS minimum standards.

7.2. As a result of an EDM meeting and the level of risk identified, a potential outcome is that RQIA intends to issue an IN. In these circumstances the Registered Person/Trust’s Responsible Individual/s will be invited to meet with RQIA to discuss RQIA’s intention to issue an IN.

7.3. The Intention to Serve IN/s Meeting should take place as soon as is practicable.

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7.4. RQIA may take enforcement action and serve an IN without convening a meeting with the Registered Person/Trust’s Responsible Individual/s, if the failure to comply with standards is considered to place the health, welfare and safety of service users at risk. See ‘Serving an Improvement Notice’ section. Intention to Serve an Improvement Notice - Meeting Preparation

7.5. A letter of invitation to meet RQIA’s representatives will be issued to the Registered Person/Trust’s Responsible Individual/s from the Head of Programme informing them of RQIA’s intention to serve an IN and requesting that they attend the meeting as a matter of urgency (appendix 3, template IN1).

7.6. Contact with the Registered Person/Trust’s Responsible Individual/s may also be made by telephone and followed up in a letter. A record of the telephone call will be retained.

7.7. In the event that a Registered Person/Trust’s Responsible Individual indicates they or an appropriate representative cannot attend on the date given in the invitation letter, the meeting may be rescheduled. The Registered Person/Trust’s Responsible Individual will be notified (appendix 3, template IN2). Intention to Serve an Improvement Notice - Meeting

7.8. The purpose of the Intention to Serve an IN Meeting is to ensure that the Registered Person/Trust’s Responsible Individual/s are fully aware of the reasons for RQIA’s Intention to Serve an IN/s and specifically to:

inform the Registered Person/Trust’s Responsible Individual/s of RQIA’s concerns about the quality and delivery of care and the failure/s to comply with any statement of DHSSPS minimum standards

provide the Registered Person/Trust’s Responsible Individual/s with an opportunity to highlight any mitigating circumstances, new facts to RQIA and to identify areas of compliance

allow RQIA to consider the information shared at the meeting.

inform the Registered Person/Trust’s Responsible Individual/s of RQIA’s decision whether to issue the required notice/s or not

inform the Registered Person/Trust’s Responsible Individual/s of the likely consequences if the improvements have not been achieved within the timescales

inform the Registered Person/Trust’s Responsible Individual/s of their right to make representation from a legal and procedural perspective

inform the Registered Person/Trust’s Responsible Individual/s of the referral of the notice/s to the relevant stakeholders and the publication of the notice/s on the ‘Current Enforcement Activity’ page of RQIA’s website (excluding children’s’ services).

7.9. A note of the Intention to Serve an IN Meeting will be taken and will include

any decisions made and actions agreed.

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Non-Attendance

7.10. In the event of non-attendance of the Registered Person/Trust’s Responsible Individual/s or their nominated representative to the Intention to Serve an IN Meeting, information will be sought to establish the reason for non-attendance. An EDM meeting will be held to determine next steps. If a valid reason for non-attendance is established, a decision may be made to reschedule the meeting. The Registered Person/Trust’s Responsible Individual/s will be notified (appendix 3, template IN2). If a valid reason is not established or if a Registered Person/Trust’s Responsible Individual/s indicates they will not be attending, a decision may be made to convene the meeting in the Registered Person/Trust’s Responsible Individual/s absence. The Registered Person/Trust’s Responsible Individual/s will be notified of the outcome of the meeting (appendix 3, template IN3).

7.11. A record of all attempts to contact the Registered Person/Trust’s Responsible Individual/s by telephone/email will be retained, including the content of any subsequent discussion. Not Serving an Improvement Notice

7.12. When a decision is made not to serve an IN, a letter detailing the outcomes of the meeting will be issued to the Registered Person/Trust’s Responsible Individual/s following the meeting by RQIA (appendix 3, template IN4). Serving an Improvement Notice

7.13. When a decision is made to serve an IN, the notice/s will be completed by the relevant inspector/s (appendix 3, template IN6).

7.14. RQIA will serve an IN on the Registered Person/Trust’s Responsible Individual/s specifying:

the specific failure/s to comply with a statement of minimum standards

the required action/s the Registered Person/Trust’s Responsible Individual/s must take to comply with a statement of minimum standards

the specific timescales within which the Registered Person/Trust’s Responsible Individual/s must take the required action will be dependent upon RQIA’s consideration of risks associated with further noncompliance

the Registered Person/Trust’s Responsible Individual/s right to make representation in respect of the notice/s. The representation arrangements are set out in the associated RQIA Enforcement Review Panel (ERP) Procedures in Respect of Improvement Notice/s

7.15. The IN/s will be accompanied by a covering letter, and should be issued

within three working days. A letter template for making representation will accompany the letter and notice. (NB: The first working day is deemed to be the day after the decision to issue the IN/s is made.) (Appendix 3, templates IN5 and IN7).

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7.16. The representation arrangements are set out in the associated RQIA Enforcement Review Panel (ERP) Procedures in Respect of Improvement Notice/s.

7.17. Where applicable, the IN/s will be sent by special delivery post and deemed served the next working day. The IN/s can be hand delivered (e.g. by courier or RQIA representative) to the Registered Person/Trust’s Responsible Individual/s’ address. If the IN/s are hand delivered, a record to confirm delivery should be obtained and held on the relevant file. Additionally and where applicable, the IN/s will be delivered by email in accordance with RQIA’s policies and procedures.

7.18. The relevant director will inform RQIA’s CEO or their nominated deputy of all notice/s served.

7.19. Copies of the IN/s will be shared with RQIA’s Communications Manager and posted on RQIA’s website (excluding children’s’ services).

7.20. All relevant stakeholders will be informed that an IN has been issued (appendix 1 – list of stakeholders). Compliance Assessment

7.21. Should the Registered Person/Trust’s Responsible Individual/s consider that compliance has been achieved before the compliance date, they should inform RQIA who will consider this information.

7.22. On the occasion where an inspection is not required, an EDM meeting must take place to record decisions made to confirm compliance.

7.23. If the Registered Person/Trust’s Responsible Individual/s has not notified RQIA that they consider compliance has been achieved before the compliance date, an inspection will be conducted of the establishment/agency/trust either on or as soon as possible after the date by which compliance must be achieved.

7.24. The inspector should inform the Head of Programme/relevant director of the outcome of the inspection as soon as possible. Compliance Achieved

7.25. RQIA will continue to monitor the quality of service provided by the establishment/agency/trust. If at any stage RQIA assesses that the establishment/agency/trust demonstrates sustained improvement and compliance, RQIA will write to the Registered Person/Trust’s Responsible Individual/s advising that compliance has been achieved (appendix 3, template IN9).

7.26. If, following the inspection, RQIA determines that compliance has been achieved, RQIA will write to the Registered Person/Trust’s Responsible Individual/s advising that compliance has been achieved (appendix 3, template IN9).

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7.27. Once compliance has been achieved the relevant IN/s will be removed from the ‘Current Enforcement Activity’ page of RQIA’s website and replaced with a clear statement of compliance (excluding children’s services). A record of past enforcement activity is available on RQIA’s website in line with its retention schedules (see relevant ‘Compliance Achieved’ sections of the website).

7.28. All relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance with IN/s (appendix 1 – list of stakeholders).

7.29. Once compliance has been achieved, RQIA’s Communications Manager will

be notified. Compliance Not Achieved

7.30. If, following the inspection RQIA determines that compliance has not been achieved, an EDM meeting will take place. The discussion at the EDM meeting will include the following areas:

review of the circumstances (including areas of compliance/noncompliance within the notice/s and an assessment of any ongoing risk

discussion of possible escalated enforcement options which may include extension of the IN/s. In these circumstances a letter confirming an extension to the compliance date of an IN will be issued along with the extended notice (appendix 3, templates IN10 and IN11).

decision about whether further legal advice should be sought

7.31. The relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance and decision to extend the IN/s (appendix 1 – list of stakeholders).

7.32. Copies of the extended IN/s will be shared with RQIA’s Communications Manager and posted on RQIA’s website (excluding children’s’ services).

7.33. RQIA may decide not to extend the compliance date of an IN as a result of lack of progress towards compliance and/or risks identified. RQIA may escalate to further enforcement.

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Enforcement Relating to Part III Establishments/Agencies Only The following sections of these procedures refer only to establishments or agencies which are registered or fall to be registered under Part III of the 2003 Order.

8. Failure to Comply Notice (FTC) (Appendix 4 – Chart 4 and 4a)

8.1. The Registered Person/s is required to comply fully with legislative requirements. Article 25 of the 2003 Order states that contravention or failure to comply with specified regulations will be an offence.

8.2. A FTC notice may be issued in respect of relevant regulations where:

an establishment or agency is in breach of regulations, including noncompliance with conditions of registration

an establishment or agency is considered to place the health and/or welfare of service users at significant risk

there is repeated failure to adequately address identified breaches in regulation within prior QIPs Note: only in exceptional circumstances should a specific requirement be stated for a third time. An EDM meeting should be held to consider what, if any, enforcement action may be required.

8.3. A FTC notice will not be issued if RQIA intends to cancel the registration of an

establishment or agency under Article 15 of the 2003 Order.

8.4. As a result of an EDM meeting and the level of risk identified, a potential outcome is that RQIA intends to issue a FTC Notice. In these circumstances the Registered Person/s will be invited to meet with RQIA to discuss RQIA’s intention to issue a FTC Notice.

8.5. The Intention to Serve a FTC Notice meeting should take place as soon as is practicable.

8.6. RQIA may take enforcement action and serve a FTC Notice without

convening a meeting with the Registered Person/s, if the breach/s is considered to place the health, welfare and safety of service users at serious risk. See ‘Serving a Failure to Comply Notice’ section. Intention to Serve a Failure to Comply Notice - Meeting Preparation

8.7. A letter of invitation to meet the Director of Regulation and Nursing (or nominated deputy), Head of Programme/Senior Inspector and relevant inspector/s will be issued to the Registered Person/s from the Director of Regulation and Nursing informing them of RQIA’s intention to serve a FTC and requesting that they attend the meeting on the date specified in the letter (appendix 3, template FTC1).

8.8. Contact with the Registered Person/s may also be made by telephone and followed up in a letter. A record of the telephone call will be retained.

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8.9. In the event that a Registered Person/s indicates they or an appropriate representative cannot attend on the date given in the invitation letter, the meeting may be rescheduled. The Registered Person/s will be notified (appendix 3, template FTC2). Intention to Serve a Failure to Comply Notice - Meeting

8.10. The purpose of the Intention to Serve a FTC Notice Meeting is to ensure that the Registered Person/s are fully aware of the reasons for RQIA’s intention to serve FTC Notice/s and specifically to:

inform the Registered Person/s formally of RQIA’s concerns about the specific failure/s of the establishment or agency

provide the Registered Person/s with an opportunity to highlight any mitigating circumstances, new facts to RQIA and to identify areas of compliance

allow RQIA to consider the information shared at the meeting.

inform the Registered Person/s of RQIA’s decision whether to issue the required notice/s or not

inform the Registered Person/s of the likely consequences if full compliance is not achieved within the identified timescales

inform the Registered Person/s formally of their right of representation from a legal and procedural perspective

inform the Registered Person/s of the referral of the notice/s to the relevant stakeholders and the publication of the notice/s on the ‘Current Enforcement Activity’ page of RQIA’s website (excluding children’s’ services).

8.11. A note of the Intention to Serve a FTC Notice Meeting will be taken and will

include any decisions made and actions agreed. Non-Attendance

8.12. In the event of non-attendance of the Registered Person/s or their nominated representative to the Intention to Serve an FTC Notice Meeting, information will be sought to establish the reason for non-attendance. An EDM meeting will be held to determine next steps. If a valid reason for non-attendance is established, a decision may be made to reschedule the meeting. The Registered Person/s will be notified (appendix 3, template FTC2. If a valid reason is either not established or if a Registered Person/s indicates they will not be attending, a decision may be made to convene the meeting in the Registered Person/s absence. The Registered Person/s will be notified of the outcome of the meeting (appendix 3, template FTC3).

8.13. A record of all attempts to contact the Registered Person/s by telephone/email will be retained, including the content of any subsequent discussion.

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Not Serving a Failure to Comply Notice

8.14. When a decision is made not to serve a FTC notice, a letter detailing the outcomes of the meeting and agreed actions will be issued to the Registered Person/s following the meeting by RQIA (appendix 3, template FTC4). Serving a Failure to Comply Notice

8.15. When a decision is made to serve FTC notice/s, the notice/s will be completed by the relevant inspector/s (appendix 3, template FTC6).

8.16. RQIA will serve a FTC notice on the Registered Person/s specifying:

the specific failing/s to comply with regulations

the required action/s the Registered Person/s must take to comply with regulations

the specific timescales within which the Registered Person/s must take the required action. This will be dependent upon RQIA’s consideration of risks associated with further noncompliance. However, the maximum period will not exceed three calendar months and commences on the issue date specified on the FTC Notice. For example, a notice with an issue date of 1 February cannot have a compliance date any later than 1 May.

the Registered Person’s right to make representation in respect of the notice/s.

8.17. The FTC notice/s will be accompanied by a covering letter, and should be issued within three working days. A letter template for making representation will accompany the letter and notice. (NB: the first working day is deemed to be the day after decision to issue the FTC notice/s is made.) (Appendix 3, templates FTC5 and FTC7)

8.18. The representation arrangements are set out in the associated RQIA Enforcement Review Panel (ERP) Procedures in Respect of Failure to Comply Notice/s.

8.19. Where applicable, the FTC notice/s will be sent by special delivery post and deemed served the next working day. The FTC notice/s can be hand delivered (e.g. by courier or RQIA representative) to the Registered Person’s address. If the FTC notice/s are hand delivered, a record to confirm delivery should be obtained and held on the relevant file (appendix 3, template FTC12). Additionally and where applicable, the FTC notice/s will be delivered by email in accordance with RQIA’s policies and procedures.

8.20. The Director of Regulation and Nursing will inform RQIA’s CEO or their nominated deputy of all notice/s served.

8.21. Copies of the FTC notice/s will be shared with RQIA’s Communications Manager and posted on RQIA’s website (excluding children’s’ services).

8.22. All relevant stakeholders will be informed that a FTC notice/s has been issued (appendix 1 – list of stakeholders).

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8.23. RQIA will continue to monitor the quality of service provided by the establishment or agency whilst enforcement action is ongoing. Compliance Assessment

8.24. Should the Registered Person/s consider that compliance has been achieved before the compliance date, they should inform RQIA who will consider this information.

8.25. On the occasion where an inspection is not required, an EDM meeting must take place to record decisions made to confirm compliance.

8.26. If the Registered Person/s has not notified RQIA that they consider compliance has been achieved before the compliance date, an inspection will be conducted of the establishment or agency either on or as soon as possible after the date by which compliance must be achieved. On the occasion that an inspection is not required, an EDM meeting will take place to record the decisions made to confirm compliance.

8.27. The inspector should inform the Senior Inspector/Head of Programme/Director of Regulation and Nursing about the outcomes of the inspection as soon as possible. Compliance Achieved

8.28. If, following the inspection, RQIA determines that compliance has been achieved, RQIA will write to the Registered Person/s confirming that RQIA is satisfied that compliance with legal requirements indicated in the notice/s has been achieved (appendix 3, template FTC9).

8.29. Once compliance has been achieved the relevant FTC notice/s will be removed from the ‘Current Enforcement Activity’ page of RQIA’s website and replaced with a clear statement of compliance (excluding children’s’ services). A record of past enforcement activity is available on RQIA’s website in line with its retention schedules (see relevant ‘Compliance Achieved’ sections of the website).

8.30. Once compliance has been achieved, RQIA’s Communications Manager will be notified.

8.31. All relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance with the FTC notice/s (appendix 1 – list of stakeholders). Compliance Not Achieved

8.32. If, following the inspection RQIA determines that compliance has not been achieved, an EDM meeting will take place. The discussion at the EDM meeting will include the following areas:

review of the circumstances (including areas of compliance/noncompliance within the notice/s and an assessment of any ongoing risk

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discussion of possible escalated enforcement options which may include extension of the FTC notice/s, not exceeding 3 calendar months from the date of issue, as described in the relevant regulations. In these a letter confirming an extension to the compliance date of a FTC notice will be issued along with the extended notice (appendix 3, templates FTC10 and FTC11)

decision about whether further legal advice should be sought

8.33. All relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance and decision to extend the FTC notice/s (appendix 1 – list of stakeholders).

8.34. Copies of any extended FTC notice/s will be shared with RQIA’s Communications Manager and posted on RQIA’s website (excluding children’s’ services).

8.35. If a FTC notice has expired, or a decision has been made not to extend as a result of lack of progress towards compliance and/or risks identified, RQIA will escalate to further enforcement action. This could include a proposal to place conditions on registration, cancel registration and/or pursuing a prosecution.

9. Notice of Proposal (NOP) (Appendix 4 – Chart 5, 6 and 7)

9.1. A NOP may be issued by RQIA under Article 18 of the 2003 Order at any time to give notice* of any decision it intends to take to:

grant an application subject to any conditions not agreed in writing between RQIA and the applicant

refuse an application to register an establishment or agency under Article 14 of the 2003 Order

cancel registration of a person in respect of an establishment or agency under Article 15 of the 2003 Order

vary or remove any condition in force in relation to the registration of the establishment or agency

impose any additional condition in relation to the registration of an establishment or agency

refuse an application of a Registered Person/applicant under Article 16 of the 2003 Order for the variation or removal of a condition relating to registration

*Except where RQIA makes an urgent application under Article 21, via a lay magistrate (formerly a Justice of the Peace), for an order to cancel the registration of a person in respect of an establishment or agency, vary, remove or impose an additional condition in relation to the registration.

9.2. An EDM meeting will take place with the Director of Regulation and Nursing, the relevant Head of Programme, Senior Inspector and relevant inspector/s (or their nominated deputies) to discuss the relevant issues regarding the establishment or agency and/or any application for registration made.

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9.3. As a result of an EDM meeting and the level of risk identified, a potential outcome is that RQIA intends to issue a NOP. In these circumstances the Registered Person/applicant will be invited to meet with and discuss RQIA’s intention to issue a NOP.

9.4. The Intention to Serve a NOP Meeting should take place as soon as is practicable.

9.5. RQIA may take enforcement action and serve a NOP without convening a meeting with the Registered Person/applicant, if the area/s of noncompliance is considered to place the health, welfare and safety of service users at serious risk. See ‘Serving a Notice of Proposal’ section. Intention to Serve a Notice of Proposal - Meeting Preparation

9.6. A letter of invitation to meet the Director of Regulation and Nursing Head of Programme/Senior Inspector and relevant inspector/s (or their nominated deputies), will be issued to the Registered Person/applicant from the Director of Regulation and Nursing informing them of RQIA’s intention to serve a NOP and requesting that they attend the meeting as a matter of urgency (appendix 3, template NOP1).

9.7. Contact with the Registered Person/applicant may also be made by telephone and followed up in a letter. A record of the telephone call will be retained.

9.8. In the event that a Registered Person/applicant indicates they or an appropriate representative cannot attend on the date given in the invitation letter, the meeting may be rescheduled. The Registered Person/applicant will be notified (appendix 3, template NOP2) Intention to Serve a Notice of Proposal - Meeting

9.9. The purpose of this meeting is to ensure that the Registered Person/applicant/s are fully aware of the reasons for RQIA’s intention to serve the NOP and specifically to:

review the circumstances (including areas of noncompliance and assessment of any ongoing risk)

provide the Registered Person/applicant with an opportunity to highlight any new facts to RQIA and identify areas of compliance

allow RQIA to consider the information shared at the meeting

inform the Registered Person/applicant of RQIA’s decision either to issue the NOP or not

should the decision be taken to issue a NOP, RQIA will inform the Registered Person/applicant of the reasons for proceeding with the notice and indicate what is proposed within the notice

inform the Registered Person/applicant formally of their right to representation from a legal and procedural perspective

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inform the Registered Person/applicant of the referral of the notice/s to the relevant stakeholders and the publication of the notice/s on the ‘Current Enforcement Activity’ page of RQIA’s website (excluding children’s’ services).

9.10. A note of the Intention to Serve a NOP meeting will be taken and will include

any decisions made and actions agreed. Non-Attendance

9.11. In the event of non-attendance of the Registered Person/applicant or their nominated representative to the Intention to Serve a NOP Meeting, information will be sought to establish the reason for non-attendance. An EDM meeting will be held to determine next steps. If a valid reason for non-attendance is established, a decision may be made to reschedule the meeting. The Registered Person/applicant will be notified (appendix 3, template NOP2). If a valid reason is either not established or if a Registered Person/applicant indicates they will not be attending, a decision may be made to convene the meeting in the Registered Person/applicant absence. The Registered Person/applicant will be notified of the outcome of the meeting (appendix 3, template NOP3).

9.12. A record of all attempts to contact the Registered Person/applicant by telephone/email will be retained, including the content of any subsequent discussion. Not Serving a Notice of Proposal

9.13. When a decision is made not to serve a NOP, a letter detailing the outcomes of the meeting will be issued to the Registered Person/applicant following the meeting by RQIA (appendix 3, template NOP4). Serving a Notice of Proposal

9.14. When a decision is made to serve a NOP, the notice will be completed by the relevant inspector/s (appendix 3, template NOP6).

9.15. RQIA will serve a NOP on the Registered Person/applicant specifying:

what RQIA are proposing

if applicable, the regulations or parts of the 2003 Order which are breached

the reasons for serving the NOP

the Registered Person/applicant’s right to make representation 9.16. The NOP will be accompanied by a covering letter, and should be issued

within three working days. A letter template for making representation will accompany the letter and notice. (NB: The first working day is deemed to be the day after the decision to issue the NOP is made) (Appendix 3, templates NOP5 and NOP7).

9.17. Where applicable, the NOP/s will be sent by special delivery post and deemed served the next working day. The NOP/s can be hand delivered (e.g. by

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courier or RQIA representative) to the Registered Person/applicant’s address. If the NOP/s are hand delivered, a record to confirm delivery should be obtained (appendix 3, template NOP10) and held on the relevant file. Additionally and where applicable, the NOP/s will be delivered by email in accordance with RQIA’s policies and procedures.

9.18. The Director of Regulation and Nursing will inform RQIA’s CEO or their nominated deputy of all notice/s served.

9.19. Copies of the NOP will be shared with RQIA’s Communications Manager and posted on RQIA's website (excluding children’s’ services and a NOP relating to refusal to register).

9.20. All relevant stakeholders will be informed that a NOP has been issued (appendix 1 – list of stakeholders). Representation

9.21. In accordance with Article 19, any person on whom a NOP has been served has the right to make written representation to RQIA within 28 days of service of the notice concerning any matter which that person wishes to dispute. The representation arrangements are set out in the associated RQIA Decision Making Panel (DMP) Procedures in Respect of Notice/s of Proposal.

9.22. The DMP may be convened by RQIA’s CEO, following receipt of written representation/s from any person on whom a NOP is served concerning any matter which that person wishes to dispute.

9.23. Where representations are received within the 28 days in respect of a NOP to vary, remove or impose conditions on registration within 28 days, a DMP will be convened as soon as is practicable.

9.24. A DMP will always be convened when RQIA proposes to either refuse to register an establishment or agency, or cancel the registration of a person in respect of an establishment or agency. The DMP will always be convened even where written notification has been received from the Registered Person/applicant confirming they do not intend to make written representations.

9.25. A DMP will review the NOP and determine whether or not it is satisfied that there are sufficient grounds to proceed with the matters outlined within the NOP. Not Adopting a Proposal

9.26. If within 28 days of serving a NOP, RQIA determines compliance has been achieved or that the matters under consideration are no longer pertinent, an EDM meeting will be held. If it is RQIA’s decision not to adopt the NOP, a letter will be forwarded to the Registered Person/applicant confirming this decision (appendix 3, template NOP9).

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9.27. If after 28 days of serving the NOP and where a DMP meeting is not required, an EDM meeting must be convened to confirm reasons for not adopting the NOP. A letter will be forwarded to the Registered Person/applicant (appendix 3, template NOP9).

9.28. If following a DMP it is RQIA’s decision not to adopt the proposal, a letter will be forwarded to the Registered Person/applicant confirming this decision. Please see RQIA Enforcement Decision Making Panel (DMP) Procedures in Respect of Notice/s of Proposal for details.

9.29. If the DMP has decided not to adopt the proposal, an EDM meeting will be

convened and the Director of Regulation and Nursing will meet with the relevant Head of Programme and inspector/s to review the situation and to make a decision on future actions. Decisions made will be recorded, including any legal advices obtained.

9.30. All relevant stakeholders and RQIA’s Communications Manager will be informed when a NOP has not been adopted (appendix 1 – list of stakeholders).

9.31. If at any stage RQIA decides not to adopt the NOP, the relevant notice/s will be removed from the Current Enforcement Activity page on RQIA’s website (excluding children’s’ services). RQIA will retain a record of past enforcement activity on its website, in line with its retention schedules.

10. Notice of Decision (NOD) (Appendix 4 – Chart 5, 6 and 7)

10.1. If RQIA decides to adopt a proposal under Article 18, it shall serve a Notice of Decision (NOD) (in accordance with Article 20) to the same person/s to whom the NOP was served.

10.2. If RQIA wish to adopt a NOP, this cannot take place until:

written representations are received from the Registered Person/applicant; or

written notification has been received that the Registered Person/applicant does not intend to make written representations; or

28 days from the date the NOP is served have elapsed.

10.3. If following 28 days of serving the NOP, RQIA have not received written representations, and a DMP is not required, an EDM meeting must be held as soon as is practicable. Where it is RQIA’s decision to adopt the NOP, see ‘Serving a Notice of Decision’ section.

10.4. Where a DM Panel has been convened and is satisfied that the refusal or cancellation of registration is appropriate, it will authorise the NOD to be issued, see ‘Serving a Notice of Decision’ section.

10.5. Where a DM Panel has been convened following a representation and is satisfied that the proposal to vary or remove, impose conditions on registration is appropriate, it will authorise the NOD to be issued, see ‘Serving a Notice of Decision’ section.

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Serving a Notice of Decision

10.6. The NOD may be issued by RQIA under Article 20 of the 2003 Order to give notice of the decision made to adopt the matters stated on the NOP.

10.7. RQIA will serve a NOD without convening a meeting with the Registered Person/applicant.

10.8. The NOD will be completed by the relevant inspector/s (appendix 3, template NOD2).

10.9. RQIA will serve a NOD on the Registered Person/applicant specifying:

what RQIA have decided

if applicable the regulations or parts of the 2003 Order which are breached

the reasons for serving the NOD

the Registered Person/applicant’s right to appeal to the Care Tribunal under Article 22 of the 2003 Order

10.10. The Director of Regulation and Nursing will inform RQIA’s CEO or their

nominated deputy of all notice/s to be served. RQIA’s CEO should ensure that a report of any refusals or cancellations of registration is brought to the next Board meeting in line with RQIA’s Standing Orders (refer to Standing Order Three).

10.11. The NOD will be accompanied by a covering letter and should be issued within three working days. (NB: The first working day is deemed to be the day after decision to issue the NOD is made) (Appendix 3, template NOD1).

10.12. Where applicable, the Notice of Decision will be sent by special delivery post and deemed served the next working day. The Notice of Decision can be hand delivered (e.g. by courier or RQIA representative) to the Registered Person/applicant’s address. If the Notice of Decision is hand delivered, a record to confirm delivery should be obtained and held on the relevant file. Additionally and where applicable, the notices will be delivered by email in accordance with RQIA’s policies and procedures.

10.13. Copies of the NOD will be shared with RQIA’s Communications Manager and posted on RQIA’s website (excluding children’s’ services and a NOD relating to refusal to register).

10.14. All relevant stakeholders will be informed that a NOD has been issued (appendix 1 – list of stakeholders). Appeals to the Care Tribunal

10.15. If the Registered Person/applicant intends to lodge an appeal with the Care Tribunal they must do so within 28 days after the serving of the NOD in line with Article 22 of the 2003 Order.

10.16. On an appeal made against the decision, the Care Tribunal may confirm the decision, or direct that it shall not have effect.

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10.17. The Care Tribunal shall also have power on an appeal against a decision:

to vary any condition for the time being in force in respect of the establishment or agency to which the appeal relates

to direct that any such condition shall cease to have affect

to direct that any such condition as it thinks fit shall have effect in respect of the establishment or agency

10.18. Following the expiration of 28 days from service of the NOD if RQIA have not

received correspondence from the Care Tribunal with notification of receipt of an appeal within the permitted timeframe, RQIA will contact the Care Tribunal to confirm no appeal has been received.

10.19. Where RQIA has been notified by the Care Tribunal of an appeal against RQIA’s decision RQIA will await written notification of the determination or withdrawal of the appeal from the Care Tribunal. RQIA will contact the Care Tribunal to seek an update on the case as appropriate. When does RQIA’s Decision Take Effect?

10.20. If a decision is taken to refuse to register an establishment or agency or a person seeking to be registered, the decision takes effect from the date the NOD is served.

10.21. Except for a decision taken as per paragraph 11.20 above, RQIA’s decision cannot take effect unless:

28 days has expired since the NOD was served and RQIA is satisfied that no appeal is made to the Care Tribunal or

an appeal made to the Care Tribunal has been determined or abandoned. However, if the NOD relates to the granting of an application subject to any conditions, which have not been agreed in writing between RQIA and the applicant, this decision shall take effect within 28 days of the service of the NOD if the applicant notifies RQIA in writing that he/she does not intend to make an appeal.

10.22. Where RQIA’s decision has been appealed to the Care Tribunal, RQIA will indicate whether or not it opposes the appeal. A decision not to oppose the appeal must originate from an EDM meeting. RQIA will notify the Care Tribunal in writing of this decision.

10.23. Following the Care Tribunal’s decision regarding an appeal against RQIA’s decision, RQIA’s CEO will write to the Registered Person/applicant advising of RQIA’s response.

10.24. RQIA’s Registration Manager will be advised of the date from which the decision takes effect and RQIA’s register will be updated accordingly, and where applicable, appropriate registration certificates issued.

10.25. RQIA’s Communications Manager will be advised of the date from which the decision takes effect and RQIA’s website will be updated accordingly.

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10.26. All relevant stakeholders will be informed of the Care Tribunal’s decision and RQIA’s response (appendix 1 – list of stakeholders).

10.27. The Director of Regulation and Nursing, Head of Programme and inspector may liaise with relevant HSC trusts and/or other stakeholders to ensure that appropriate action is taken to safeguard the health and wellbeing of service users. RQIA may invite relevant stakeholders to a meeting to discuss the circumstances and any relevant contingency arrangements.

10.28. In the period after the decision has taken effect, RQIA will continue to monitor the quality of service provided by the establishment or agency. If RQIA assesses that the establishment or agency demonstrates sustained improvement and compliance RQIA may decide not to implement all or part of the decision.

10.29. RQIA’s Registration Manager will be advised of any changes to RQIA’s register which will be updated accordingly, and where applicable registration certificates issued.

10.30. RQIA’s Communications Manager and all relevant stakeholders will be advised of all or any parts of the decision not being implemented and RQIA’s website will be updated accordingly. Removal or Variation of Imposed Conditions

10.31. Where condition/s have been imposed and are in force in relation to the registration of an establishment or agency, if RQIA determines that the condition/s is no longer required and intends to remove a condition/s or determines that the condition should be varied, RQIA will issue a NOP. Please see ‘Serving NOP’ section.

10.32. RQIA’s Registration Manager will be advised of any changes to RQIA’s register which will be updated accordingly.

10.33. RQIA’s Communications Manager will be informed and RQIA’s website will be updated accordingly (excluding children’s services).

10.34. Where condition/s have been imposed and are in force in relation to the registration of an establishment or agency, all relevant stakeholders will be informed when any condition in relation to registration is removed or varied (appendix 1 – list of stakeholders).

11. Urgent Procedure (Appendix 4 – Chart 8)

11.1. Under Article 21 of the 2003 Order, RQIA can apply to a Lay Magistrate for an order to:

cancel the registration of a person in respect of an establishment or agency

vary or remove any condition of registration

impose an additional condition

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11.2. If RQIA has serious concerns about a service user’s life, health or wellbeing, and is considering urgent procedures, an EDM meeting will be held. If a decision is made to apply for an order under Article 21, a record of the decision is made.

11.3. RQIA will seek legal advice on the application and the completion of an evidential report to be presented to a Lay Magistrate (appendix 3, template UP1).

11.4. In the preparation of the application, the Director of Regulation and Nursing and Head of Programme must ensure that the following matters are clearly indicated:

details of the regulations and/or parts of the 2003 Order breached including relevant enforcement history of noncompliance;

evidence to support RQIA’s application for an order and specific statements about the risks to a service user’s life, health or wellbeing if the order is not made.

11.5. In line with RQIA’s Standing Order Three, a DM Panel will always be

convened and RQIA’s CEO or (in his/her absence) the relevant director, will present the proposed application, relevant inspection report/s and related documents, and any legal advices obtained, to the DM Panel. Please refer to RQIA Decision Making Panel (DM Panel) Procedures in Respect of Urgent Procedures.

11.6. The Director of Regulation and Nursing, Head of Programme and inspector will liaise with relevant HSC trusts and/or other stakeholders to ensure that appropriate action is taken to safeguard the life, health and wellbeing of service users.

11.7. It should be noted that the DM Panel will make its determination promptly and within two working days of receipt of the application.

11.8. If the DM Panel approves the proposed application, it will authorise the application to be made to the Lay Magistrate on behalf of RQIA. The DM Panel will present a report of this decision at the next Board meeting.

11.9. As soon as practicable after the making of an application for an order, RQIA will notify the DoH and the relevant stakeholders of the making of the application.

11.10. All relevant stakeholders will be informed of the application (appendix 1 – list of stakeholders).

11.11. If a Lay Magistrate makes an order it shall have effect from the time when the order is made.

11.12. The order will be sent with a covering letter confirming a right of appeal to the Care Tribunal (appendix 3, template UP2). However it should be noted that the order takes effect from the day it is made unless directed otherwise by the Care Tribunal.

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11.13. Where applicable, the order will be sent by special delivery post and deemed served the next working day. The order can be hand delivered (e.g. by courier or RQIA representative) to the Registered Person’s address. If the order is hand delivered, a record to confirm delivery should be obtained and held on the relevant file and deemed served on the date it is signed for (appendix 3, template UP3).

11.14. Depending on the circumstances, RQIA may invite relevant stakeholders to a meeting to discuss the situation and contingency arrangements to ensure the safety and wellbeing of service users in the establishment or agency or until the situation is resolved.

11.15. RQIA’s Registration Manager will be advised of any changes to RQIA’s register which will be updated accordingly.

11.16. RQIA’s Communications Manager will be informed and RQIA’s website will be updated accordingly.

11.17. All relevant stakeholders will be informed as soon as is practicable after the making of the order (appendix 1 – list of stakeholders). Appeals to the Care Tribunal

11.18. If a Registered Person intends to lodge an appeal with the Care Tribunal they must do so within 28 days of the order being served, as outlined under Article 22 of the 2003 Order.

11.19. Following the Care Tribunal’s decision regarding a Registered Person’s appeal against an order, RQIA’s CEO will write to the Registered Person confirming RQIA’s response to the Care Tribunal’s decision.

11.20. RQIA’s Registration Manager will be advised of any changes to RQIA’s register which will be updated accordingly.

11.21. RQIA’s Communications Manager will be informed and RQIA’s website will be updated accordingly.

11.22. All relevant stakeholders will be informed of the Care Tribunal’s decision and RQIA’s response (appendix 1 – list of stakeholders).

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12. Other Actions RQIA May Take in Respect to Services Not Falling Under Part III of the 2003 Order

12.1. RQIA will consider its powers and duties under the Mental Health (Northern Ireland) Order 1986 (the 1986 Order), in respect of relevant services falling under the 1986 Order and take steps as necessary.

12.2. In accordance with Article 4 of the 2003 Order, RQIA reserves the right to advise the DoH of any matters relating to the quality or availability of services. Where there are concerns about services that do not fall to be registered under Part III of the 2003 Order, RQIA may, in accordance with Article 35 of the 2003 Order, report such concerns to the DoH and may recommend the DoH take special measures in relation to the body or service provider in question.

Appendix 1

RQIA’s Stakeholders

Appendix 1

RQIA’s Stakeholders RQIA will share details of enforcement action with relevant stakeholders. It should be noted that the below list of stakeholders is not exhaustive:

Chief Executive, Belfast Health and Social Care Trust

Chief Executive, Northern Health and Social Care Trust

Chief Executive, Western Health and Social Care Trust

Chief Executive, Southern Health and Social Care Trust

Chief Executive, South Eastern Health and Social Care Trust

Chief Executive, Regional Health and Social Care Board

Director, Safety Quality and Patient Experience, Public Health Agency

Chief Executive, Northern Ireland Social Care Council

Chief Executive, General Dental Council

Chief Executive, General Medical Council

Chief Executive, Health and Safety Executive for Northern Ireland

Chief Executive, Human Fertilisation and Embryology Authority

Chief Dental Officer, Department of Health

Chief Executive, Northern Ireland Environmental Agency

Director of Safety, Quality and Standards, Department of Health

Appendix 2

RQIA’s Quality Improvement Plan

Appendix 2

Quality Improvement Plan

Action required to ensure compliance with (insert regulations)

Area for improvement 1 Ref: Regulation xx Stated: First/Second/Third time To be completed by: insert date

The registered person shall xxx

Response by registered person detailing the actions taken:

Area for improvement 2 Ref: Regulation xx Stated: First/Second/Third time To be completed by: insert date

The registered person shall xxx

Response by registered person detailing the actions taken:

Action required to ensure compliance with (Insert standards)

Area for improvement 1 Ref: Standard xx Stated: First/Second/Third time To be completed by: insert date

The registered person shall xxx

Response by registered person detailing the actions taken:

Area for improvement 2 Ref: Standard xx Stated: First/Second/Third time To be completed by: insert date

The registered person shall xxx

Response by registered person detailing the actions taken:

Appendix 3

Associated Templates

Unregistered Services Templates

Reference Title

UR1 Proceed to Register an Establishment/Agency Letter

UR2 Cease Operation Letter

UR3 Hand Delivery Record for Letters

UR1: Proceed to Register an Establishment/Agency Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Name of Establishment/Agency Address of Establishment/Agency Non-Registration of an Establishment/Agency The Regulation and Quality improvement Authority (RQIA) has reasonable cause to believe that you are operating an establishment/agency which requires to be registered under Part III of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (2003 Order). The following contingency plan has been agreed with the Chief Executive of the insert name of trust, to ensure the safety and welfare of service users insert contingency plan. It is important that you make application to register with RQIA without delay and that you cooperate with the arrangements within the contingency plan. Please be advised that should you fail to apply to register this establishment/agency, RQIA will have no recourse except to take legal action against you as you are committing an offence. Yours sincerely Chief Executive c c : Director of Regulation and Nursing

UR2: Cease Operation Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Name of Establishment/Agency Address of Establishment/Agency Non-Registration of an Establishment/Agency The Regulation and Quality improvement Authority (RQIA) has reasonable cause to believe that you are operating an establishment/agency which requires to be registered under Part III of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (2003 Order). To continue operating, this establishment/agency is committing an offence and you are instructed to cease operations from insert todays date. The Chief Executive of the insert name of trust has been informed of this decision and of the trust’s responsibility to ensure that suitable arrangements have been made for the welfare of all service users. Please confirm by insert date that you have ceased to operate. If you ignore this notice and continue to operate, RQIA will have no recourse except to take legal action against you, as you are committing an offence under the aforementioned Order. Yours sincerely Chief Executive cc : Director of Regulation and Nursing

Communications Manager, RQIA Relevant stakeholders

UR3: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person:

Name of Establishment/Agency:

Address of Establishment/Agency:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Serious Concerns Templates

Reference Title

SC1 Serious Concerns Meeting Invitation Letter

SC2 Serious Concerns Meeting Reschedule Letter

SC3 Non Attendance of Registered Person/Trust’s Responsible Individual to a Serious Concerns Meeting

SC4 Serious Concerns Meeting Outcomes Letter

SC5 Hand Delivery Record for Serious Concerns Letters

SC1: Invitation to SC meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Invitation to a Serious Concerns Meeting Name of establishment/agency/trust Address of establishment/agency/trust Insert as appropriate: The Regulation and Quality Improvement Authority (RQIA) has concerns that you may be carrying on or managing an establishment/agency that is required to be registered with RQIA in accordance with Article 12 of the Health and Personal Social Services (Quality Improvement and Regulation) (Northern Ireland) Order 2003. RQIA raised these matters during the previous visit/correspondence. OR Insert as appropriate: The Regulation and Quality Improvement Authority (RQIA) has concerns that the quality of care and service within insert name of establishment/agency/trust falls below the standard expected with respect to the following areas: Insert relevant Regulation/s/Standard/s and detail issues Insert as appropriate: RQIA raised these matters during the previous insert number inspections of insert name of establishment/agency/trust on insert dates insert as appropriate: and during subsequent discussions by telephone. Unfortunately, despite RQIA's efforts to support and encourage improvements in the service, it is our view that insufficient progress has been made with respect to all of the matters indicated above. In view of our concerns, I would wish to discuss these matters with you and invite you to attend a Serious Concerns Meeting at this office on insert date at insert time. Insert name of inspector will also be in attendance at the meeting. Insert as appropriate: RQIA would also request that insert additional person/s name/s should also be in attendance. Insert as appropriate: In preparation for this meeting, I would request that you complete a draft action plan outlining how you intend to address the matters identified.

SC1: Invitation to SC meeting

The draft action plan should include the following: actions to be taken; by whom; and within a specified timescale. Please contact insert name of admin support at this office on insert telephone number to confirm your attendance. If any special arrangements are required to enable attendance at the meeting, please let us know. If you require any further information please contact insert name of Head of Programme/Inspector. Your cooperation in this matter would be greatly appreciated.

Yours sincerely Head of Programme cc: relevant director

SC2: Reschedule to SC meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Change of Serious Concerns Meeting Date Name of establishment/agency/trust Address of establishment/agency/trust Further to my previous correspondence inviting you to attend a Serious Concerns Meeting relating to the above establishment/agency/trust, insert name of Registered Person/Trust’s Responsible Individual has advised he/she is unable to attend. The date has been rearranged to insert date at insert time at RQIA’s office, Belfast. Please contact insert name of admin support at this office on insert telephone number to confirm your attendance. If any special arrangements are required to enable attendance at the meeting, please let us know. Your cooperation in this matter would be greatly appreciated. Yours sincerely Head of Programme cc: relevant director

SC3: Non Attendance to SC Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Serious Concerns Meeting Name of establishment/agency/trust Address of establishment/agency/trust With reference to our concerns about the quality of care and service within insert name of establishment/agency/trust, detailed in correspondence sent to you on insert date, the Regulation and Quality Improvement Authority (RQIA) invited you to a meeting on insert date to discuss the following concerns: Insert relevant Regulation/s/Standard/s and detail issues RQIA contacted you/made attempts to contact you on insert date by letter/email/phone call. Insert history of communication between RQIA and Registered Person/Trust’s Responsible Individual which resulted in lack of attendance. Insert as appropriate: In view of your lack of attendance at the meeting RQIA is unable to establish that the necessary improvements in the quality of care and service within insert name of establishment/agency/trust have been made. RQIA has considered the matter and wish to confirm that we have decided to insert decisions/agreements/specific action/s. RQIA will continue to monitor and review the quality of service provided in insert name of establishment/agency/trust insert as appropriate: and will/may carry out an inspection to assess compliance with these standards/regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action.

SC3: Non Attendance to SC Meeting

If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Head of Programme cc: relevant director

SC4: SC Meeting Outcomes Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Summary of Serious Concerns Meeting Name of establishment/agency/trust Address of establishment/agency/trust With reference to our concerns about the quality of care and service within insert name of establishment/agency/trust, detailed in correspondence sent to you on insert date, the Regulation and Quality Improvement Authority (RQIA) held a meeting with you/your representative, insert their name on insert meeting date. At this meeting we discussed the following concerns: Insert relevant Regulation/s/Standard/s and detail issues Insert as appropriate: At this meeting, you/your representative, insert their name provided a full account of the actions/arrangements you have made/will make to ensure the minimum improvements necessary to achieve compliance with the standards identified. OR Insert as appropriate: At this meeting, you/your representative, insert their name provided clarification in relation to the concerns that RQIA outlined to you in writing on insert date. You/your representative provided assurances that the establishment/agency/trust is operating in accordance with the relevant standards and/or regulations and these assurances were accepted by RQIA. OR Insert as appropriate: At this meeting, you/your representative, insert their name were unable to provide RQIA with assurances that sufficient progress had been made on required areas for quality improvement within your establishment/agency/trust, insert detail of issues where progress had not been made. RQIA has considered the matter and wish to confirm that we have decided to insert decisions/agreements/specific actions/take no further action.

SC4: SC Meeting Outcomes Letter

RQIA will continue to monitor and review the quality of service provided in insert name of establishment/agency/trust insert if appropriate: and will/may carry out an inspection to assess compliance with these standards/regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/Inspector.. Yours sincerely Head of Programme cc: relevant director

SC5: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person/Trust’s Responsible Individual:

Name of Establishment/Agency/Trust:

Address of Establishment/Agency/Trust:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Improvement Notice/s Templates

Reference Title

IN1 Intention to Serve Improvement Notice/s Meeting Invitation

Letter

IN2 Intention to Serve Improvement Notice/s Meeting Reschedule

Letter

IN3 Non Attendance of Registered Person/trust’s Responsible Individual to an Intention to Serve Improvement Notice/s Meeting

IN4 Intention to Serve Improvement Notice/s Meeting Outcomes

Letter – Not Serving Improvement Notice/s

IN5 Intention to Serve Improvement Notice/s Meeting Outcomes

Letter – Serving Improvement Notice/s

IN6 Improvement Notice

IN7 Right to Make Representation Template

IN8 Reissue - Improvement Notice/s Covering Letter

IN9 Improvement Notice/s Compliance Letter

IN10 Extension Improvement Notice

IN11 Extension Improvement Notice Covering Letter

IN12 Hand Delivery Record for Improvement Notice/s and Letters

IN1: Invitation to Intention to Serve an IN Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Invitation to an Intention to Serve an Improvement Notice/s Meeting Name of establishment/agency/trust Address of establishment/agency/trust This letter should be considered as a notice of the Regulation and Quality Improvement Authority’s (RQIA) intention to serve insert number Improvement Notice/s to you, in respect of failure/s to comply with the following standards: Insert relevant standard/s and detail of issues RQIA raised these matters during the previous insert number inspections of insert name of establishment/agency/trust on insert dates insert as appropriate: and during subsequent discussions by telephone. Unfortunately, despite RQIA's efforts to support and encourage improvements in the service, it is our view that insufficient progress has been made with respect to all of the matters indicated above. In view of our concerns, I would wish to discuss these matters with you and invite you to attend an Intention to Issue an Improvement Notice meeting at this office on insert date at insert time. Insert name of inspector/representative from RQIA will also be in attendance at the meeting. Insert as appropriate: RQIA would also request that insert additional person/s name/s should also be in attendance. Insert as appropriate: In preparation for this meeting, RQIA would request that you complete a draft action plan outlining how you intend to address the matters identified. The draft action plan should include the following: actions to be taken; by whom and within a specified timescale. Please contact insert name of admin support at this office on insert telephone number to confirm your attendance.

IN1: Invitation to Intention to Serve an IN Meeting

If any special arrangements are required to enable attendance at the meeting, please let us know. If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Head of Programme cc: relevant director

IN2: Reschedule to Intention to Serve IN Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Change of Intention to Serve an Improvement Notice Meeting Date Name of establishment/agency/trust Address of establishment/agency/trust Further to my previous correspondence inviting you to attend an Intention to Serve an Improvement Notice/s Meeting relating to the above establishment/agency/ trust, you/your representative has advised you are unable to attend. The date of this meeting has been rearranged to insert date at insert time at RQIA’s office, Belfast. Please contact insert name of admin support on insert telephone number to confirm your attendance. If any special arrangements are required to enable attendance at the meeting, please let us know. Your cooperation in this matter would be greatly appreciated. Yours sincerely Head of Programme cc: relevant director

IN3: Non Attendance to Intention to Serve an IN Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/trust’s Responsible Individual Address of Registered Person/trust’s Responsible Individual Dear Name of Registered Person/trust’s Responsible Individual Intention to Serve Improvement Notices Meeting Name of establishment/agency/trust Address of establishment/agency/trust With reference to correspondence sent to you on insert date regarding our intention to serve insert number Improvement Notice/s, the Regulation and Quality Improvement Authority (RQIA) arranged a meeting on insert meeting date to discuss our concerns about your failure to comply with the following minimum standards: Insert relevant Standard/s and detail of issues Insert as appropriate: In spite of RQIA’s attempts to contact you on insert dates by letter/email/phone call, you did not attend the above meeting which was convened in your absence. Insert as appropriate: In view of your lack of attendance at the meeting RQIA is unable to establish that the necessary improvements to address the failure/s to comply with the minimum standards have been made. RQIA has considered the matter and wish to confirm that we have decided to insert decisions/agreements/specific action/s/serve IN/s. Insert as appropriate: If a notice is to be served this will be served under separate correspondence. RQIA will continue to monitor the quality of service provided in insert name of establishment/agency/trust insert as appropriate: and may/will carry out an inspection to assess compliance with these standards and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Head of Programme cc: relevant director

IN4: IN Meeting Outcome Letter - Not Serving IN

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Confirmation of Decision – Not Serving Improvement Notice/s Name of establishment/agency/trust Address of establishment/agency/trust This letter confirms RQIA’s decision following a meeting held with you/your representative, insert their name on insert meeting date to discuss our concerns about your noncompliance with the following standards: Insert relevant Standard/s and detail issues At this meeting, you/your representative, insert name provided a full account of the actions/arrangements you have made/will make to ensure the minimum improvements necessary to achieve compliance with the standards identified. RQIA has considered the matter and wish to confirm that we have decided not to serve insert number Improvement Notice/s in regard to the above standards. Insert as necessary: However, it was agreed at the meeting that insert specific action/s/agreement/s referred to: RQIA will continue to monitor and review the quality of service provided in insert name of establishment/agency/trust insert if appropriate: and may carry out an inspection to assess compliance with these standards and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Inspector. Yours sincerely Head of Programme cc: relevant director

IN5: Intention to Serve IN Meeting Outcomes Letter – Serving IN

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Improvement Notice/s Name of establishment/agency/trust Address of establishment/agency/trust IN Ref: Insert IN Reference With reference to our intention to serve insert number Improvement Notice/s in respect of failure to comply with the minimum standards, detailed in correspondence sent to you on insert date. The Regulation and Quality Improvement Authority (RQIA) invited you to a meeting on insert date. Insert as appropriate: RQIA contacted you/made attempts to contact you on insert date by letter/email/phone call insert history of communication between RQIA and Registered Person/Trust’s Responsible Individual which resulted in lack of attendance. Insert as appropriate: In view of your lack of attendance at the meeting RQIA is unable to establish that the necessary improvements to address the failure/s to comply with the minimum standards within insert name of establishment/Agency/Trust have been made. In accordance with Article 39 of the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, The Regulation and Quality Improvement Authority (RQIA) has decided to serve insert number of Improvement Notice/s in respect of a failure to comply with the following statements of minimum standards: Insert relevant Standard/s and detail issues RQIA requires that the necessary improvements outlined in the attached notice/s are implemented by you within the identified timescales, in order to ensure full compliance with these standards. Should you decide that compliance has been achieved before the compliance due date, you should inform RQIA who will consider this information and may conduct an earlier inspection. You will be informed whether compliance has been achieved/not achieved.

IN5: Intention to Serve IN Meeting Outcomes Letter – Serving IN

You may make formal representations to RQIA in regard to the issuing of an Improvement Notice, by writing to the Chief Executive, using the template provided, within one calendar month of receipt of the notice, stating the precise reasons for making the representation. You are deemed to have received this/these notice/s on the next working day after the date of posting or on the day you received this/these by hand delivery. Should you have any queries regarding this matter, I would be grateful if you could contact RQIA immediately. A copy of the Improvement Notice/s will be forwarded to all relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. Once compliance has been achieved, relevant notice/s will be removed from the ‘Current Enforcement Activity’ webpage and a clear statement of compliance with the relevant notice will be placed on RQIA’s website (excluding childrens’ services). RQIA will retain a record of past enforcement activity, in line with its retention schedules. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/name of Inspector. Yours sincerely Relevant Director Enc. cc: relevant Head of Programme

IN6: Improvement Notice

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

IMPROVEMENT NOTICE

Name of Registered establishment/agency/trust: Insert name of establishment/agency/trust (RQIA ID: Insert ID Number)

Name of Registered Person/Trust’s Responsible Individual: Insert name of Registered Person/Trust’s Responsible Individual

Address of registered establishment/agency/Trust: Insert address of establishment/agency/trust

Issue Date: Insert date IN Ref: Insert IN Reference

Minimum standard requiring improvement: Insert relevant standard

Specific failings to comply with the statement of minimum standard: Insert failing/s

Improvements necessary to achieve compliance: Insert action/s

The Registered Person/s/trust’s Responsible Individual/s may make written

representations to the Chief Executive of RQIA regarding the issue of an Improvement Notice, within one month of the date of serving this notice.

Date by which compliance must be achieved: Insert date

Signed………………………………………… Director of ……………..

This notice is served under Article 38 and 39 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003

and The Department of Health, Social Services and Public Safety.

It should be noted that failure to comply with the measures identified in this Improvement Notice may result in further enforcement action by RQIA.

IN7: Right to Make Representation Template

Reference

Insert Date The Chief Executive Regulation and Quality Improvement Authority Riverside Tower 5 Lanyon Place Belfast BT1 3BT Dear Right to Make Representation – Improvement Notice/s in respect of: Insert name of establishment/agency/trust Insert address of establishment/agency/trust In line with the Regulation and Quality Improvement Authority’s (RQIA) Enforcement Policy, I wish to make written representation regarding the above received by me on insert date. I make my representation on the following point/s:-

______________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________

I would be grateful if you could acknowledge receipt of this letter and inform me of the outcome of your decision in line with RQIA’s enforcement policy and procedures.

Yours sincerely

Registered Person/Trust’s Responsible Individual

IN8: Reissue IN Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/trust’s Responsible Individual Address of Registered Person/trust’s Responsible Individual Dear Name of Registered Person/trust’s Responsible Individual Improvement Notice/s - Reissued Name of establishment/agency/trust Address of establishment/agency/trust IN Ref: Insert IN Reference I refer to correspondence issued to you on insert original issue date regarding insert name of establishment/agency/trust. The Improvement Notice/s contained insert reason for reissue. I apologise for any inconvenience this may cause and enclose amended version/s for your attention. I would be grateful if you would arrange for any distributed copies of the correspondence dated insert original issue date to be withdrawn and replaced with these amended version/s. A copy of the amended Improvement Notice/s will be forwarded to the relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. If you require any further information please contact insert name of HOP or name of Inspector/representative from RQIA. Yours sincerely Relevant director Enc. cc: relevant Head of Programme

IN9: IN Compliance Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Improvement Notice/s - Compliance Name of establishment/agency/trust Address of establishment/agency/trust IN Ref: Insert IN Reference The Regulation and Quality Improvement Authority (RQIA) issued insert number of Improvement Notice/s to you, in relation to insert name of establishment/agency/ trust in respect to a failure to comply with a statement of minimum standards. The Improvement Notice/s specified the failings to comply with the statement of minimum standards, improvements necessary to achieve compliance and the timescales within which they should be made. The Improvement Notice/s expired on insert dates and an inspection of insert name of establishment/agency/trust by insert name of inspector/s/representative from RQIA on insert date found that you have made the necessary improvements to comply with the statement of minimum standards set out in the notice/s. The Improvement Notice/s will be removed from the current enforcement activity page of RQIA’s website and replaced with a clear statement of compliance. The relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance. As the Registered Person/trust’s Responsible Individual you are required to ensure continued compliance with legislative requirements and minimum standards. If you require any further information please contact insert name of HOP/name of Inspector. Thank you for your cooperation throughout this process. Yours sincerely Relevant director cc: relevant Head of Programme

IN10: Extension Improvement Notice

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

IMPROVEMENT NOTICE

Name of Registered Establishment/Agency/Trust: Insert name of establishment/agency/trust (RQIA ID: Insert ID Number)

Name of Registered Person/trust’s Responsible Individual: Insert name of Registered Person/Trust’s Responsible Individual

Address of Registered Establishment or Agency/Trust: Insert address of establishment/agency/trust

Issue Date: Insert date Extended From: Insert date IN Ref: Insert IN Reference

Minimum standard requiring improvement: Insert relevant standard

Specific failings to comply with the statement of minimum standard: Insert failing/s

Improvements necessary to achieve compliance: Insert action/s

The Registered Person/s/trust’s Responsible Individual/s may make written

representations to the Chief Executive of RQIA regarding the issue of an Improvement Notice, within one month of serving of the original notice issued

to you on the above date.

Date by which compliance must be achieved: Insert date

Signed………………………………………… Director of ……………..

This notice is served under Article 38 and 39 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003

and The Department of Health, Social Services and Public Safety.

It should be noted that failure to comply with the measures identified in this Improvement Notice may result in further enforcement action by RQIA.

IN11: Extension IN Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Trust’s Responsible Individual Address of Registered Person/Trust’s Responsible Individual Dear Name of Registered Person/Trust’s Responsible Individual Improvement Notice/s – Extension of Timescale Name of establishment/agency/trust Address of establishment/agency/trust IN Ref: Insert IN Reference The Regulation and Quality Improvement Authority (RQIA) issued insert number of Improvement Notice/s to you, in relation to insert name of establishment/agency/ trust in respect to a failure to comply with a statement of minimum standards. The Improvement Notice/s specified the failings to comply with the statement of minimum standards, improvements necessary to achieve compliance and the timescales within which they should be made. The Improvement Notice/s expired on insert dates or RQIA were informed insert date informed and by whom that compliance had been achieved before the compliance date. An inspection of insert name of establishment/agency/trust by insert name of inspector/s on insert date found that you have made some progress to comply with the statement of minimum standards set out in the notice/s. Therefore, RQIA has decided to extend the compliance date for the above Improvement Notice/s, to allow you to achieve full compliance with the standards. It is important that RQIA is notified in writing when the necessary improvements have been made but no later than the date specified in the notice/s. RQIA will conduct an inspection of the establishment/agency/trust either on or as soon after the date by which compliance must be achieved. Should you decide that compliance has been achieved before the compliance due date, you should inform RQIA who will consider this information and may conduct an earlier inspection. You will be informed whether compliance has been achieved/not achieved. A copy of the extended Improvement Notice/s will be forwarded to all relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk Once compliance has been achieved, the relevant notice/s will be removed from the Current Enforcement Activity webpage and a clear statement of compliance with the relevant notice/s will be placed on RQIA’s website. RQIA will retain a record of past enforcement activity, in line with its retention schedules.

IN11: Extension IN Covering Letter

It should be noted that if there is no significant improvement and/or full compliance is not achieved within the revised timescales, RQIA may take further enforcement action. If you require any further information please contact insert name of HOP/name of Inspector. Thank you for your continued cooperation. Yours sincerely Relevant director Enc. cc: relevant Head of Programme

IN12: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person/Trust’s Responsible Individual:

Name of Establishment/Agency/Trust:

Address of Establishment/Agency/Trust:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Failure to Comply Notice/s Templates

Reference Title

FTC1 Intention to Serve Failure to Comply Notice/s Meeting Invitation Letter

FTC2 Intention to Serve Failure to Comply Notice/s Meeting Reschedule Letter

FTC3 Non Attendance of Registered Person to an Intention to Serve Failure to Comply Notice/s Meeting

FTC4 Intention to Serve Failure to Comply Notice/s Meeting Outcomes Letter – Not Serving Failure to Comply Notice/s

FTC5 Intention to Serve Failure to Comply Notice/s Meeting Outcomes Letter – Serving Failure to Comply Notice/s

FTC6 Failure to Comply Notice

FTC7 Right to Make Representation Template

FTC8 Reissue - Failure to Comply Notice/s Covering Letter

FTC9 Failure to Comply Notice/s Compliance Letter

FTC10 Extension Failure to Comply Notice/s

FTC11 Extension Failure to Comply Notice/s Covering Letter

FTC12 Hand Delivery Record for Failure to Comply Notice/s and Letters

FTC1: Invitation to Intention to Serve FTC meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Invitation to an Intention to Serve a Failure to Comply Notice/s Meeting Name of establishment/agency Address of establishment/agency This letter should be considered as a notice of the Regulation and Quality Improvement Authority’s (RQIA) intention to serve insert number Failure to Comply Notice/s to you, in respect of noncompliance with the following regulations: Insert relevant regulation/s and detail of issues RQIA raised these matters during the previous insert number inspections of insert name of establishment/agency on insert dates insert as appropriate: and during subsequent discussions by telephone. RQIA are concerned that you have not made the improvements necessary to ensure full compliance with the required regulations. RQIA would wish, as a matter of urgency, to meet with you to discuss the specific failings in service, the minimum improvement/s necessary to ensure compliance and the timescales within which the improvements should be made. It should be noted that continued noncompliance may lead to further enforcement action. A meeting has been arranged at this office on insert date at insert time. Insert name of inspector/representative from RQIA will also be in attendance at the meeting. Insert as appropriate: RQIA would also request that insert additional person/s name should be in attendance. Please contact insert name of admin support at this office on insert telephone number to confirm your attendance.

FTC1: Invitation to Intention to Serve FTC meeting

If any special arrangements are required to enable attendance at the meeting, please let us know. If you require any further information please contact insert name of Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

FTC2: Reschedule to FTC Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Change of Intention to Serve a Failure to Comply Notice/s Meeting Date Name of establishment/agency Address of establishment/agency Further to my previous correspondence inviting you to attend an Intention to Serve Failure to Comply Notice/s Meeting relating to the above establishment/agency, you/your representative has advised that you are unable to attend. The date for this meeting has been rearranged to insert date at insert time at RQIA offices, Belfast. Please contact insert name of admin support on insert telephone number to confirm your attendance. If any special arrangements are required to enable attendance at the meeting, please let us know. Your cooperation in this matter would be greatly appreciated. Yours sincerely Head of Programme cc: Director of Regulation and Nursing

FTC3: Non Attendance to Intention to Serve FTC meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Intention to Serve a Failure to Comply Notice/s Meeting Name of establishment/agency Address of establishment/agency With reference to correspondence sent to you on insert date regarding our intention to serve insert number Failure to Comply Notice/s, the Regulation and Quality Improvement Authority (RQIA) arranged a meeting on insert meeting date to discuss our concerns about your noncompliance with the following regulations: Insert relevant Regulation/s and detail of issues Insert as appropriate: In spite of RQIA’s attempts to contact you on insert dates by letter/email/phone call, you did not attend the above meeting which was convened in your absence. Insert as appropriate: In view of your lack of attendance at the meeting, RQIA is unable to establish that the necessary actions to address the noncompliance with regulation/s have been made. RQIA has considered the matter and wish to confirm that we have decided to insert decisions/agreements/specific action/s/serving FTC/s. Insert as appropriate: If a notice is to be served this will be served under separate correspondence. RQIA will continue to monitor the quality of service provided in insert name of establishment/agency insert as appropriate: and may/will carry out an inspection to assess compliance with these regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

FTC4: FTC Meeting Outcome Letter - Not Serving FTC

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Confirmation of Decision – Not Serving Failure to Comply Notice/s Name of establishment/agency Address of establishment/agency This letter confirms RQIA’s decision following a meeting held with you/your representative, insert their name on insert meeting date to discuss our concerns about your noncompliance with the following regulations: Insert relevant Regulation/s and detail of issues At this meeting, you/your representative, insert their name provided a full account of the insert as appropriate: actions/arrangements you have made/will make to ensure the improvements necessary to achieve full compliance with the required regulations. RQIA has considered the matter and wish to confirm that we have decided not to serve insert number Failure to Comply Notice/s in regard to the above regulations. Insert as necessary: However, it was agreed at the meeting that insert specific action/s/agreement/s referred to: RQIA will continue to monitor and review the quality of service provided in insert name of establishment/agency insert if appropriate: and may carry out an inspection to assess compliance with these regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. It should also be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for specified offences. If you require any further information please insert name of Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

FTC5: Intention to Serve FTC Meeting Outcomes Letter – Serving FTC

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Failure to Comply Notice/s Name of establishment/agency Address of establishment/agency FTC Ref: Insert FTC Reference The Regulation and Quality Improvement Authority (RQIA) has decided to serve insert number Failure to Comply Notice/s in respect of noncompliance with the following regulations: Insert relevant Regulation/s and detail issues As the Registered Person you must take immediate action to implement the measures contained in the attached notice/s in order to ensure full compliance with the regulations indicated. It is important that RQIA is notified in writing when the action required has been completed but no later than the date/s specified in the notice/s. RQIA will carry out an inspection of insert name of establishment/agency to ensure compliance with identified regulations, as detailed in the Failure to Comply Notice/s by the date/s specified. Should you decide that compliance has been achieved before the compliance due date, you should inform RQIA who will consider this information and may conduct an earlier inspection. You will be informed whether compliance has been achieved/not achieved. I would advise you that any Registered Person failing to comply with the requirements specified in the Failure to Comply Notice/s within the specified timescale/s, may be guilty of an offence against these regulations and may be subject to further legal action. It should also be noted that under regulations RQIA has the power to prosecute for specified offences. You may make formal representations to RQIA in regard to the issuing of a Failure to Comply Notice, by writing to the Chief Executive, using the template provided, within one calendar month of receipt of the notice, stating the precise reasons for making the representation. You are deemed to have received this/these notice/s on the next working day after the date of posting or on the day you received this/these by hand delivery.

FTC5: Intention to Serve FTC Meeting Outcomes Letter – Serving FTC

Should you have any queries regarding this matter, I would be grateful if you could contact RQIA immediately. A copy of the Failure to Comply Notice/s will be forwarded to all relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. Once compliance has been achieved, relevant notice/s will be removed from the Current Enforcement Activity webpage and a clear statement of compliance will be placed on RQIA’s website (excluding childrens’ services). RQIA will retain a record of past enforcement activity, in line with its retention schedules. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing Enc. cc: relevant Head of Programme

FTC6: FTC Notice

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

FAILURE TO COMPLY NOTICE

Name of Registered Establishment or Agency: Insert name of establishment/agency (RQIA ID: Insert ID Number)

Name of Registered Person: Insert name of Registered Person

Address of registered establishment or agency: Insert address of establishment/agency

Issue Date: Insert date FTC Ref: Insert FTC Reference

Regulation not complied with: Insert relevant regulation

Specific failings to comply with regulations: Insert failing/s

Action required to comply with regulations: Insert action/s

The Registered Person may make written representations to the Chief Executive

of RQIA regarding the issue of a failure to comply notice, within one month of the date of serving this notice.

Date by which compliance must be achieved: Insert date

Signed………………………………………… Director of Regulation of Nursing

This notice is served under The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 and The insert name

of regulations (Northern Ireland) (insert date)

It should be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for

specified offences.

FTC7: Right to Make Representation Template

Reference

Insert Date The Chief Executive Regulation and Quality Improvement Authority Riverside Tower 5 Lanyon Place Belfast BT1 3BT Dear Right to Make Representation – Failure to Comply Notice/s in respect of: Insert name of establishment/agency Insert address of establishment/agency In line with the Regulation and Quality Improvement Authority’s (RQIA) Enforcement Policy, I wish to make written representation regarding the above received by me on insert date. I make my representation on the following point/s:-

___________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________

I would be grateful if you could acknowledge receipt of this letter and inform me of the outcome of your decision in line with RQIA’s enforcement policy and procedures.

Yours sincerely

Registered Person

FTC8: Reissue FTC Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Failure to Comply Notice/s - Reissued Name of establishment/agency Address of establishment/agency FTC Ref: Insert FTC Reference I refer to correspondence issued to you on insert original issue date regarding insert name of establishment or agency. The Failure to Comply Notice/s contained insert reason for reissue. I apologise for any inconvenience this may cause and enclose amended version/s for your attention. I would be grateful if you would arrange for any distributed copies of the correspondence dated insert original issue date to be withdrawn and replaced with these amended version/s. A copy of the amended Failure to Comply Notice/s will be forwarded to the relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. If you require any further information please contact insert name of Head of Programme/name of Inspector. Yours sincerely Director of Regulation and Nursing Enc. cc: relevant Head of Programme

FTC9: FTC Compliance Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Failure to Comply Notice/s - Compliance Name of establishment/agency Address of establishment/agency FTC Ref: Insert FTC Reference The Regulation and Quality Improvement Authority (RQIA) issued insert number of Failure to Comply Notice/s to you, in relation to insert name of establishment/agency in respect to a breach in regulations. The Failure to Comply Notice/s specified the noncompliance with regulations, actions required for compliance and the timescales within which they should be made. The Failure to Comply Notice/s expired on insert dates and an inspection of insert name of establishment/agency by insert name of inspector/s on insert date found that you have made the necessary improvements to comply with the regulations set out in the notice/s. The Failure to Comply Notice/s will be removed from the current enforcement activity page of RQIA’s website and replaced with a clear statement of compliance. The relevant stakeholders will be informed of the outcome of RQIA’s assessment of compliance. As the Registered Person you are required to ensure continued compliance with legislative requirements and minimum standards. If you require any further information please contact insert name of HOP/name of Inspector. Thank you for your cooperation throughout this process. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

FTC10: Extension FTC Notice

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

FAILURE TO COMPLY NOTICE Name of Registered Establishment/Agency: Insert name of establishment/agency (RQIA ID: Insert ID Number)

Name of Registered Person: Insert name of Registered Person/s

Address of Registered Establishment or Agency: Insert address of establishment/agency

Issue Date: Insert date Extended From: Insert date FTC Ref: Insert FTC Reference

Regulation not complied with:

Insert relevant regulation

Specific failings to comply with regulations: Insert failing/s

Action required to comply with regulations: Insert action/s

The Registered Person may make written representations to the Chief Executive of RQIA regarding the issue of a Failure to Comply Notice, within one month of

serving of the original notice issued to you on the above date.

Date by which compliance must be achieved: Insert date

Signed………………………………………… Director of Regulation of Nursing

This notice is served under The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 and The insert name

of regulations (Northern Ireland) (insert date)

It should be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for

specified offences.

FTC11: Extension FTC Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Failure to Comply Notice/s – Extension of Timescale Name of establishment/agency Address of establishment/agency FTC Ref: Insert FTC Reference The Regulation and Quality Improvement Authority (RQIA) issued insert number of Failure to Comply Notice/s to you, in relation to insert name of establishment/agency in respect of breaches in regulations. The Failure to Comply Notice/s specified the failings to comply with the regulations, improvements necessary to achieve compliance and the timescales within which they should be made. The Failure to Comply Notice/s expired on insert dates or RQIA were informed insert date informed and by whom that compliance had been achieved before the compliance date. An inspection of insert name of establishment/agency by insert name of inspector/s on insert date found that you have made some progress to comply with the regulations set out in the notice/s. Therefore, RQIA has decided to extend the compliance date for the above Failure to Comply Notice/s, to allow you to achieve full compliance with the regulations. RQIA will conduct an inspection of the establishment/agency either on or as soon after the date by which compliance must be achieved. Should you decide that compliance has been achieved before the compliance due date, you should inform RQIA who will consider this information and may conduct an earlier inspection. You will be informed whether compliance has been achieved/not achieved. A copy of the extended Failure to Comply Notice/s will be forwarded to all relevant stakeholders and RQIA’s Communication Manager the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. Once compliance has been achieved, relevant notice/s will be removed from the Current Enforcement Activity webpage and a clear statement of compliance with the relevant notice/s will be placed on RQIA’s website. RQIA will retain a record of past enforcement activity, in line with its retention schedules.

FTC11: Extension FTC Covering Letter

It should be noted that if there is no significant improvement and/or full compliance is not achieved within the revised timescales, RQIA may take further enforcement action. If you require any further information please contact insert name of HOP/name of Inspector. Thank you for your continued cooperation. Yours sincerely Director of Regulation and Nursing Enc. cc: relevant Head of Programme

FTC12: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person:

Name of Establishment/Agency:

Address of Establishment/Agency:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Notice/s of Proposal Templates

Reference Title

NOP1 Intention to Serve Notice/s of Proposal Meeting Invitation Letter

NOP2 Intention to Serve Notice/s of Proposal Meeting Reschedule Letter

NOP3 Non Attendance of Registered Person/applicant to an Intention to Serve Notice/s of Proposal Meeting

NOP4 Intention to Serve Notice/s of Proposal Meeting Outcomes Letter – Not Serving Notice/s of Proposal

NOP5 Intention to Serve Notice/s of Proposal Meeting Outcomes Letter – Serving Notice/s of Proposal

NOP6 Notice of Proposal

NOP7 Right to Make Representation Template

NOP8 Reissue - Notice/s of Proposal Covering Letter

NOP9 Not Adopting the Proposal Letter

NOP10 Hand Delivery Record for Notice/s of Proposal and Letters

NOP1: Invitation to Intention to Serve NOP Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Invitation to an Intention to Serve a Notice/s of Proposal Meeting Name of establishment/agency Address of establishment/agency This letter should be considered as notice of the Regulation and Quality Improvement Authority's (RQIA) intention to serve insert number Notice/s of Proposal to insert what RQIA are proposing, in respect of noncompliance with the following regulations: Insert relevant regulation/s and detail of issues RQIA raised these matters during the previous insert number inspections of insert name of establishment/agency on insert dates insert as appropriate: and during subsequent discussions by telephone. RQIA are concerned that you have not made the improvements necessary to ensure full compliance with the required regulations. RQIA would wish, as a matter of urgency, to meet with you to discuss the specific failings in service, the minimum improvement/s necessary to ensure compliance and the timescales within which the improvements should be made. It should be noted that continued noncompliance may lead to further enforcement action. A meeting has been arranged at this office on insert date at insert time. Insert name of inspector/representative from RQIA will also be in attendance at the meeting. Insert as appropriate: RQIA would also request that insert additional person/s name should also be in attendance. Please contact insert name of admin support at this office on insert telephone number to confirm your attendance.

NOP1: Invitation to Intention to Serve NOP Meeting

If any special arrangements are required to enable attendance at the meeting, please let us know. If you require any further information please contact insert name Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOP2: Reschedule to Intention to Serve NOP Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Change of Intention to Serve Notice/s of Proposal Meeting Date Name of establishment/agency Address of establishment/agency Further to my previous correspondence inviting you to attend an Intention to Serve Notice/s of Proposal Meeting relating to the above establishment/agency, you/your representative has advised that you are unable to attend. The date for this meeting has been rearranged to insert date at insert time at RQIA offices, Belfast. Please contact insert name of admin support on insert telephone number to confirm your attendance. If any special arrangements are required to enable attendance at the meeting, please let us know. Your cooperation in this matter would be greatly appreciated. Yours sincerely Head of Programme cc: Director of Regulation and Nursing

NOP3: Non Attendance to Intention to Serve NOP Meeting

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Intention to Serve Notice/s of Proposal Meeting Name of establishment/agency Address of establishment/agency With reference to correspondence sent to you on insert date regarding our intention to serve insert number Notice/s of Proposal, the Regulation and Quality Improvement Authority (RQIA) arranged a meeting on insert meeting date to discuss our concerns about your noncompliance with the following regulations: Insert relevant Regulation/s and detail of issues Insert as appropriate: In spite of RQIA’s attempts to contact you on insert dates by letter/email/phone call, you did not attend the above meeting which was convened in your absence. Insert as appropriate: In view of your lack of attendance at the meeting, RQIA is unable to establish that the necessary actions to address the noncompliance with regulation/s have been made. RQIA has considered the matter and wish to confirm that we have decided to insert decisions/agreements/specific action/s/serving NOP/s. Insert as appropriate: If a notice is to be served this will be served under separate correspondence. RQIA will continue to monitor the quality of service provided in insert name of establishment/agency insert as appropriate: and may/will carry out an inspection to assess compliance with these regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. If you require any further information please contact insert name of Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOP4: NOP Meeting Outcome Letter - Not Serving NOP

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Confirmation of Decision – Not Serving Notice/s of Proposal Name of establishment/agency Address of establishment/agency With reference to previous correspondence sent to you on insert date regarding our intention to serve insert number Notice/s of Proposal, the Regulation and Quality Improvement Authority’s (RQIA) held a meeting with you/your representative, insert their name on insert meeting date to discuss our concerns about your noncompliance with the following regulations: Insert relevant Regulation/s and detail of issues At this meeting, you/your representative, insert their name provided a full account of the insert as appropriate: actions/arrangements you have made/will make to ensure the improvements necessary to achieve full compliance with the required regulations. RQIA have has considered the matter and wish to confirm that we have decided not to serve insert number Notice/s of Proposal in regard to the above regulations. Insert as necessary: However, it was agreed at the meeting that insert specific action/s/agreement/s referred to. Delete if NOP refers to a refusal to register: RQIA will continue to monitor and review the quality of service provided in insert name of establishment/agency insert if appropriate: and may carry out an inspection to assess compliance with these regulations and will keep you informed of the outcome. It should be noted that continued noncompliance may lead to further enforcement action. It should also be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for specified offences.

NOP4: NOP Meeting Outcome Letter - Not Serving NOP

If you have any queries regarding this matter, require any further information please do not hesitate to contact me or insert name of Head of Programme/Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOP5: Intention to Serve NOP Meeting Outcome Letter – Serving NOP

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Notice/s of Proposal to insert as appropriate: Impose any Additional Condition in Relation to the Registration; Vary and Remove any Condition; Cancel Registration; Refuse an Application Name of establishment/agency Address of establishment/agency NOP Ref: Insert NOP Reference This letter gives you notice under Article 18 of The Health and Personal Social Services (Quality, Improvement and Regulation)(Northern Ireland) Order 2003, (the 2003 Order) that RQIA proposes to insert what is being proposed e.g. cancel registration; vary or remove or impose the following condition/s in relation to insert name of establishment/agency. A copy of the Notice/s of Proposal is attached. RQIA has issued this Notice/s of Proposal explain reasons succinctly with reference to inspection reports/previous documents etc. in regard to evidential trail. Under Article 19 of the 2003 Order, you have the right to make written representation to the Chief Executive using the template provided, within 28 days of service of this notice, stating the precise reasons for making representation. You are deemed to have received this/these notice/s on the next working day after the date of posting or on the day you received this/these by hand delivery. Should you have any queries regarding this matter, I would be grateful if you could contact RQIA immediately. RQIA will consider any written representations you make within 28 days of service of this notice before deciding whether or not to adopt this proposal and you will be informed of the outcome. If RQIA decides to adopt this proposal, you will receive a formal notice of this decision, which will confirm your right of appeal to the Care Tribunal. Insert as appropriate: When RQIA proposes to cancel the registration of a person in respect of an establishment or agency, or refuse to register an establishment or agency, the Chief Executive of RQIA will always convene a Decision Making Panel Meeting following 28 days of the service of this/these notice/s.

NOP5: Intention to Serve NOP Meeting Outcome Letter – Serving NOP

A copy of the Notice/s of Proposal will be forwarded to all relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. Once compliance has been achieved the relevant notice/s will be removed from the Current Enforcement Activity webpage and a clear statement of compliance will be placed on RQIA’s website (excluding childrens’ services). RQIA will retain a record of past enforcement activity, in line with its retention schedules. Please contact insert name of Head of Programme/Inspector if you wish to discuss this/these notice/s or there is anything in this/these notice/s that you do not understand. Yours sincerely Chief Executive Enc. cc: Director of Regulation and Nursing

NOP6: Notice of Proposal

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

NOTICE OF PROPOSAL

Name of Registered Establishment or Agency: Insert name of establishment/agency (RQIA ID: Insert ID Number)

Name of Registered Person/ Applicant: Insert name of Registered Person/Applicant

Address of registered establishment or agency: Insert address of establishment/agency

Issue Date: Insert date NOP Ref: Insert NOP Reference

The Regulation and Quality Improvement Authority gives notice of a proposal to insert what is being proposed a) grant an application for registration subject to condition(s) which have not

been agreed in writing b) refuse an application for registration c) cancel registration d) vary or remove any condition e) impose any additional condition f) refuse an application by a Registered Person/s for the variation or removal

of any condition relating to registration Insert relevant regulation

The reasons for serving this Notice of Proposal are: Insert reasons

Under Article 19 of the 2003 Order, the Registered Person/Applicant may, within 28 days of the service of this notice, make written representations to the Chief Executive of RQIA concerning any matter which that person wishes to dispute.

Signed………………………………………… Director of Regulation of Nursing

This notice is served under Article 18 of The Health and Personal Social

Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003

It should be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for

specified offences.

NOP7: Right to Make Representation Template

Reference

Insert Date The Chief Executive Regulation and Quality Improvement Authority Riverside Tower 5 Lanyon Place Belfast BT1 3BT Dear Right to Make Representation – Notice/s of Proposal in respect of: Insert name of establishment/agency Insert address of establishment/agency In line with the Regulation and Quality Improvement Authority’s (RQIA) Enforcement Policy, I wish to make written representation regarding the above received by me on insert date. I make my representation on the following point/s:-

___________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________

I would be grateful if you could acknowledge receipt of this letter and inform me of the outcome of your decision in line with RQIA’s enforcement policy and procedures.

Yours sincerely

Registered Person/Applicant

NOP8: Reissue NOP Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Notice/s of Proposal - Reissued Name of establishment/agency Address of establishment/agency NOP Ref: Insert NOP Reference I refer to correspondence issued to you on insert original issue date regarding insert name of establishment/agency. The Notice/s of Proposal contained insert reason for reissue. I apologise for any inconvenience this may cause and enclose amended version/s for your attention. I would be grateful if you would arrange for any distributed copies of the correspondence dated insert original issue date to be withdrawn and replaced with these amended version/s. A copy of the amended Notice/s of Proposal will be forwarded to the relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. If you require any further information please contact insert name of Head of Programme/name of Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOP9: Not Adopting the Proposal

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Confirmation of Decision – Not Adopting the Proposal Name of establishment/agency Address of establishment/agency NOP Ref: Insert NOP Reference With reference to previous correspondence sent to you on insert date regarding our proposal to insert what is being proposed e.g. cancel registration; vary or remove or impose the following condition/s in relation to insert name of establishment or agency. The Notice of Proposal stated the regulations/part of the 2003 Order breached and RQIA are now satisfied that you have made the necessary improvements to comply with Regulations set out in the notice. Delete if NOP refers to a refusal to register: As the Registered Person I would wish to remind you that you are required to ensure continued compliance with legislative requirements and minimum standards relevant to your establishment or agency. Thank you for your cooperation throughout this process. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOP10: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person/Applicant:

Name of Establishment/Agency:

Address of Establishment/Agency:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Notice/s of Decision Templates

Reference Title

NOD1 Serving Notice/s of Decision Covering Letter

NOD2 Notice of Decision

NOD3 Reissue Notice of Decision

NOD4 NOD Taking Effect Letter

NOD5 Not Proceeding with Decision Letter

NOD6 Hand Delivery Record for Notice/s of Decision and Letters

NOD1: Serving NOD Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Notice/s of Decision to insert as appropriate: Impose any Additional Condition in Relation to the Registration; Vary and Remove any Condition; Cancel Registration; Refuse an Application Name of establishment/agency Address of establishment/agency NOD Ref: Insert NOD Reference The Regulation and Quality Improvement Authority (RQIA) issued a Notice of Proposal to you on insert date under Article 18 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (the 2003 Order). The notice confirmed our proposal/s to insert as appropriate: impose any additional condition in relation to the registration; vary and remove any condition; cancel registration; refuse an application in relation to insert name of establishment/agency. The Notice of Proposal also informed you of your right to make written representation to RQIA under Article 19 of the 2003 Order within 28 days, concerning any matter contained within the Notice of Proposal which you may wish to dispute. Insert as appropriate: The period for making written representation expired on insert date insert as appropriate: and RQIA can confirm that no written representation was received from insert name of establishment/agency within this timescale. A copy of the Notice of Decision is attached which confirms the following actions to be taken on the registration of insert name of establishment/agency: Insert actions Our reasons for reaching this decision are insert details. Under Article 22 of the 2003 Order, you have a right to appeal to the Care Tribunal within 28 days from the date of service of this notice. The notice period for appeal expires on insert date. You are deemed to have received this notice the next working day after postage, or on the day of hand delivery. Insert as appropriate: In line with Article 20 of the 2003 Order, it should be noted that the decisions indicated in this notice will not take effect until the expiration of the 28

NOD1: Serving NOD Covering Letter

day period, or if an appeal is made, until the appeal is determined or abandoned by the Care Tribunal. Insert as appropriate: As the Registered Person I would wish to remind you that you should continue to address the issues identified in the Failure to Comply Notice/s issued on insert date. A copy of the Notice/s of Decision will be forwarded to all relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. Once compliance has been achieved the relevant notice/s will be removed from the Current Enforcement Activity webpage and a clear statement of compliance will be placed on RQIA’s website (excluding childrens’ services). RQIA will retain a record of past enforcement activity, in line with its retention schedules. If you wish to discuss these/this notice/s please contact me or insert name of Head of Programme/Inspector. Yours sincerely Chief Executive Enc. cc: Director of Regulation and Nursing

NOD2: Notice of Decision

THE REGULATION AND QUALITY IMPROVEMENT AUTHORITY (RQIA)

NOTICE OF DECISION

Name of Registered Establishment or Agency: Insert name of establishment/agency (RQIA ID: Insert ID Number)

Name of Registered Person/ Applicant: Insert name of Registered Person/Applicant

Address of registered establishment or agency: Insert address of establishment/agency

Issue Date: Insert date NOD Ref: Insert NOD Reference

The Regulation and Quality Improvement Authority gives notice of a decision to insert what has been decided a) grant an application for registration subject to condition(s) which have not

been agreed in writing b) refuse an application for registration c) cancel registration d) vary or remove any condition e) impose any additional condition f) refuse an application by a Registered Person/s for the variation or removal

of any condition relating to registration Insert relevant regulation

The reasons for serving this Notice of Decision are: Insert reasons

Under Article 22 of the 2003 Order the Registered Person/Applicant may, within

28 days of the service of this notice, make an appeal to the Care Tribunal concerning any matter which that person wishes to dispute.

Signed……………………………………………………………… Chief Executive

This notice is served under Article 20 of The Health and Personal Social

Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003.

It should be noted that failure to comply with some regulations is considered to be an offence and RQIA has the power under regulations to prosecute for

specified offences.

NOD4: Reissue NOD Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Notice/s of Decision - Reissued Name of establishment/agency Address of establishment/agency NOD Ref: Insert NOD Reference I refer to correspondence issued to you on insert original issue date regarding insert name of establishment or agency. The Notice/s of Decision contained insert reason for reissue. I apologise for any inconvenience this may cause and enclose amended version/s for your attention. I would be grateful if you would arrange for any distributed copies of the correspondence dated insert original issue date to be withdrawn and replaced with these amended version/s. A copy of the amended Notice/s of Decision will be forwarded to the relevant stakeholders and RQIA’s Communication Manager on the day of issue for posting on the enforcement pages on RQIA’s website www.rqia.org.uk. If you require any further information please contact insert name of Head of Programme/name of Inspector. Yours sincerely Director of Regulation and Nursing cc: relevant Head of Programme

NOD5: NOD Taking Effect Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Notice/s of Decision to insert as appropriate: Impose any Additional Condition in Relation to the Registration; Vary and Remove any Condition; Cancel Registration; Refuse an Application Name of establishment/agency Address of establishment/agency NOD Ref: Insert NOD Reference The Regulation and Quality Improvement Authority (RQIA) issued a Notice of Proposal to you on insert date under Article 18 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 (the 2003 Order). The notice confirmed our proposal/s to insert as appropriate: impose any additional condition in relation to the registration; vary and remove any condition; cancel registration; refuse an application in relation to insert name of establishment/agency. RQIA then issued a Notice of Decision, insert date. The Notice of Decision informed you of the right to appeal to the Care Tribunal under Article 22 of the 2003 Order. Insert as appropriate: On insert date, RQIA received confirmation from the Care Tribunal that no appeals against this Notice of Decision had been made. Or Insert as appropriate: On insert date, RQIA received confirmation from the Care Tribunal that your appeal against this Notice of Decision was not upheld. In line with Article 20 of the 2003 Order, it should be noted that the decisions indicated in the notice dated 10 January 2017 will now take effect. RQIA’s website www.rqia.org.uk will be updated to reflect this decision. We will retain a record of this enforcement activity, in line with our retention schedules. If you wish to discuss any aspect of this letter please contact insert name of Head of Programme. Yours sincerely Chief Executive cc: Director of Regulation and Nursing

NOD5: Not Proceeding with Decision Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person/Applicant Address of Registered Person/Applicant Dear Name of Registered Person/Applicant Confirmation of Decision – Decision Not to Proceed Name of establishment/agency Address of establishment/agency NOD Ref: Insert NOD Reference With reference to previous correspondence sent to you on insert date regarding the Notice of Decision to insert as appropriate: impose any additional condition in relation to the registration; vary and remove any condition; cancel registration; refuse an application in relation to insert name of establishment/agency. The Notice of Decision stated the regulations/part of the 2003 Order breached and RQIA are now satisfied that you have made the necessary improvements to comply with regulations set out in the notice. Delete if NOD refers to a refusal to register: As the Registered Person I would wish to remind you that you are required to ensure continued compliance with legislative requirements and minimum standards relevant to your establishment or agency. RQIA’s website www.rqia.org.uk will be updated to reflect this decision. We will retain a record of this enforcement activity, in line with our retention schedules. If you wish to discuss any aspect of this letter please contact insert name of Head of Programme. Yours sincerely Chief Executive cc: Director of Regulation and Nursing

NOD3: Hand Delivery Record

Hand Delivery Record of Enforcement Documents

Name of Registered Person/Applicant:

Name of Establishment/Agency:

Address of Establishment/Agency:

Address Enforcement Documents Hand Delivered to:

Enforcement Document/s Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Urgent Procedure Templates

Reference Title

UP1 Application

UP2 Order Covering Letter

UP3 Hand Deliver Record for Order

UP1: Application

Urgent Procedure Ref: Insert Reference Application for Cancellation of Registration or to Vary, Remove or Impose a Condition of Registration Name of establishment/agency Address of establishment/agency Under Article 21 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 the Regulation and Quality Improvement Authority (RQIA) is making an application to a lay magistrate for an order to insert as appropriate one of the following: a. cancel the registration of a person b. vary or remove any condition of registration c. impose an additional condition in regard to insert detail of establishment/agency or registered person. RQIA is making this application due to: cite regulations breached, specific statements as to nature of breaches, succinctly state why urgent action is necessary and include concerns about any risks to a service user's life, health or well-being. Ensure the level of risk is clearly identified to enable the court to make a decision about giving notice to the registered person in regard to this application. (Article 21.-(2)). Signed Chief Executive

Date

UP2: Order Covering Letter

Reference Date PRIVATE AND CONFIDENTIAL Name of Registered Person Address of Registered Person Dear Name of Registered Person Urgent Procedure for Cancellation of Registration or to Vary, Remove or Impose a Condition of Registration Name of establishment/agency Address of establishment/agency Urgent Procedure Ref: Insert Reference Under Article 21 of The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 the Regulation and Quality Improvement Authority (RQIA) made application to a Lay Magistrate for an order insert as appropriate one of the following: a) cancelling the registration of a person in respect of an establishment or agency: b) varying or removing any condition for the time being in force c) imposing an additional condition in regard to insert detail of establishment/agency or Registered Person as appropriate. RQIA made this application to the Lay Magistrate due to: cite regulations breached, specific statements as to nature of breaches, succinctly state why urgent action is necessary and include concerns about any risks to a service user's life, health or well-being if the order is not made. Ensure the level of risk is clearly identified to enable the court to make a decision about giving notice to the registered person in regard to this application. The Lay Magistrate made the order on insert date and the order has taken effect from that date. All relevant stakeholders and RQIA’s Communication Manager will be informed and

RQIA’s website will be updated accordingly.

UP2: Order Covering Letter

Under Article 22 of the 2003 Order, you have a right to appeal to the Care Tribunal within 28 days from the date of service of this order. The notice period for appeal expires on insert date. You are deemed to have received this order the next working day after postage, or on the day of hand delivery. Yours sincerely Chief Executive cc Director of Regulation and Nursing

Communications Manager

UP3: Hand Delivery Record

Hand Delivery Record of Court Order

Name of Registered Person:

Name of Establishment/Agency:

Address of Establishment/Agency:

Address Court Order Hand Delivered to:

Court Order Description including any reference numbers:

By signing the below I confirm receipt of the above documents: Received by:

(signature)

(PRINTED) Date:

Time:

Delivered by:

(signature)

(PRINTED) Designation:

*Any reason for non-delivery must be indicated:

Appendix 4

Enforcement Process Flow Charts

EDM Meeting Procedure

Issues of Concern Identified

Discussion Held with Head of Programme/

Senior Inspector

EDM MeetingMonitor Issues of Concern

Chart 1

Serious

Concerns

Procedure

(Chart 2)

Improvement

Notice

Procedure

(Chart 3 and 3a)

Failure to

Comply

Procedure

(Chart 4 and 4a)

Notice of Proposal/

Notice of Decision

Procedure

(Chart 5, 6 and 7)

Urgent

Procedure

(Chart 8)

Decision made to hold a Serious

Concerns Meeting

Letter of Invitation to Serious

Concerns Meeting issued to

Registered Person/trust’s

Responsible Individual

EDM Meeting

(see chart 1)

No further enforcement action required

Did the

Registered Person/trust’s

Responsible Individual

attend the meeting?

NO

YES

Compliance achieved/

satisfactory action plan in

place?

NO

Letter confirming meeting

outcomes issued to Registered

Person/trust’s Responsible

Individual

Is establishment/agency

/trust compliant?YES NO

EDM Meeting

(see chart 1)

Serious Concerns Procedure

Chart 2

Letter rescheduling Serious

Concerns Meeting issued to

Registered Person/trust’s

Responsible Individual

Letter confirming meeting

outcomes issued to Registered

Person/trust’s Responsible

Individual

YES

Monitoring or further inspection

carried out to assess compliance

Representation

made?

Improvement Notice Procedure

Decision made to advise

Registered Person/trust’s Responsible

Individual of intention to issue an

Improvement Notice/s

Convene meeting in Registered

Person/trust’s Responsible Individual’s

absence

Serve Improvement Notice/s and issue

representation guidance to Registered

Person/trust’s Responsible Individual

Chart 3

Letter confirming meeting outcomes

issued to Registered Person/trust’s

Responsible IndividualNo further enforcement action required

Inform stakeholders, Communications

Manager and update RQIA’s website

Letter confirming Intention to Serve

Improvement Notice/s Meeting date

issued to Registered Person/trust’s

Responsible Individual

Did the

Registered Person/trust’s

Responsible Individual attend

the meeting?

Reschedule Meeting

Satisfactory evidence of

compliance received?

EDM Meeting

(see chart 1)NO

YES

YES

NO

YES

See Improvement Notice Procedure

– Extending a Notice

(see chart 3a)

Inform stakeholders, Communications

Manager and update RQIA’s website

Letter confirming compliance issued to

Registered Person/trust’s Responsible

Individual

YES

Satisfactory evidence of

compliance received?NO

EDM Meeting

(see chart 1)

See ERP Procedures

(Document 3)

Satisfactory evidence of

compliance received?

Serve Extended Improvement Notice/s

to Registered Person/trust’s

Responsible Individual

Inform stakeholders, Communications

Manager and update RQIA’s website

EDM Meeting

(see chart 1)

Improvement Notice Procedure – Extending a Notice

Decision made to extend an

Improvement Notice/s

Chart 3a

NO

Letter confirming compliance issued to

Registered Person/trust’s Responsible

IndividualYES

Inform stakeholders, Communications

Manager and update RQIA’s website

Representation

made?

Failure to Comply Notice Procedure Decision made to advise

Registered Person/s of intention to

issue Failure to Comply Notice/s

Convene meeting in Registered

Person’s absence

Serve Failure to Comply Notice/s and

issue representation guidance to

Registered Person/s

Chart 4

Letter confirming meeting outcomes

issued to Registered Person/sNo further enforcement action required

Inform stakeholders, Communications

Manager and update RQIA’s website

Letter confirming Intention to Serve

Failure to Comply Notice/s Meeting

date issued to Registered Person/s

Did the

Registered Person/s attend the

meeting?

Reschedule Meeting

Satisfactory evidence of

compliance received?

EDM Meeting

(see chart 1)NO

YES

YES

NO

YES

See Failure to Comply Procedure

– Extending a Notice

(see chart 4a)

Inform stakeholders, Communications

Manager and update RQIA’s website

Letter confirming compliance issued to

Registered Person/trust’s Responsible

Individual

EDM Meeting

(see chart 1)

YES

Satisfactory evidence of

compliance received?NO

See ERP Procedures

(Document 4)

Failure to Comply Notice Procedure – Extending a Notice

Decision made to extend

Failure to Comply Notice/s

Chart 4a

NO

Letter confirming compliance issued to

Registered Person/sYES

Serve Extended Failure to Comply

Notice/s to Registered Person/s

Inform stakeholders, Communications

Manager and update RQIA’s website

Satisfactory evidence of

compliance received?

EDM Meeting

(see chart 1)

Inform stakeholders, Communications

Manager and update RQIA’s website

Decision made to issue

Notice/s of Proposal

Did the

Registered Person/s attend

the meeting?

Satisfactory evidence of

compliance received?

Reschedule Meeting

Convene meeting in Registered

Person/s absence

Serve Notice/s of Proposal and

issue representation guidance to

Registered Person/s

Serve Notice of Decision to the

Registered Person/s

(takes effect after 28 days of service if

no appeal is made to the care tribunal)

NO

YESNo further enforcement action required

NO

NO

YES

Inform stakeholders Registration

Manager, Communications

Manager and update RQIA’s

website

Letter confirming Intention to

Serve Notice/s of Proposal

Meeting date issued to

Registered Person/s

Satisfactory evidence of

compliance received?

NO

Chart 5

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

Not Serving letter issued to

Registered Person/s

Notice of Proposal/Notice of Decision Procedure

To Cancel Registration

Decision made to

adopt the proposal?

Inform stakeholders Registration

Manager, Communications Manager,

RQIA’s Board and update RQIA’s

website

Appeal submitted to

Care Tribunal?

EDM Meeting

(see chart 1)RQIA’s decision confirmed?

Letter of confirmation issued to

Registered Person/s NO YES

Letter of compliance issued to

Registered Person/ApplicantYES

Inform stakeholders Registration

Manager, Communications Manager

and update RQIA’s website

See DMP Procedures

(Document 5)

YES

See DMP Procedures

(Document 5)NO

Letter confirming decision takes effect sent to

Registered Person/s and request registration

certificate returned immediately

Inform stakeholders Registration

Manager, Communications Manager

and update RQIA’s website

Inform stakeholders Registration

Manager, Communications

Manager and update RQIA’s

website

YES

Decision made to issue

Notice/s of Proposal

Did the

Registered Person/

Applicant attend

the meeting?

YES

Satisfactory evidence of

compliance received?

Reschedule Meeting

Convene meeting in Registered

Person/Applicant’s absence

Serve Notice/s of Proposal and

issue representation guidance to

Registered Person/Applicant

Serve Notice of Decision to the

Registered Person/Applicant

(takes immediate effect)

NO

YESNo further enforcement action required

NO

Inform Registration Manager

Letter confirming Intention to

Serve Notice/s of Proposal

Meeting date to Registered

Person/Applicant

NO

Appeal submitted to

Care Tribunal?

YES

YESNO

Inform Communications Manager

and Registration Manager

Inform Registration Manager

and The Board

Notice of Proposal/Notice of Decision Procedure

To Refuse An Application for Registration

Chart 6

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

Letter of compliance issued to

Registered Person/Applicant

Satisfactory evidence of

compliance received?

Letter of compliance issued to

Registered Person/Applicant

Decision made to

adopt the proposal?

RQIA’s decision confirmed?

Letter of compliance issued to

Registered Person/ApplicantLetter of confirmation issued to

Registered Person/Applicant

No further enforcement action requiredNO

YES

See DMP Procedures

(Document 5)

YES

See DMP Procedures

(Document 5)NO

Inform Registration Manager

Decision made to issue

Notice/s of Proposal

Did the

Registered Person/

Applicant attend

the meeting?

Satisfactory evidence of

compliance received?

Reschedule Meeting

Convene meeting in Registered

Person/Applicant’s absence

Serve Notice/s of Proposal and

issue representation guidance to

Registered Person/Applicant

YES

Serve Notice of Decision to the

Registered Person/Applicant

YES

NO

YESNo further enforcement action required

NO

Appeal submitted to

Care Tribunal?NO

YES

YESNO

Letter confirming Intention to

Serve Notice/s of Proposal

Meeting date issued to

Registered Person/Applicant

Inform stakeholders Registration

Manager, Communications Manager,

The Board and update RQIA’s website

Inform stakeholders Registration

Manager, Communications Manager

and update RQIA’s website

Letter confirming Notice of Decision takes effect sent to

Registered Person/applicant and request registration

certificate returned immediately

Chart 7

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

Letter of compliance issued to

Registered Person/Applicant

Notice of Proposal/Notice of Decision Procedure

To Grant an Application Subject to any

Conditions Not agreed in Writing

To Vary or Remove any Condition

To Impose any Additional Condition on

Registration

Satisfactory evidence of

compliance received?

Representation

made?

YES

EDM Meeting

(see chart 1)

Letter of compliance issued to

Registered Person/Applicant

NODecision made to

adopt the proposal?

RQIA’s decision confirmed?

Letter of confirmation issued to

Registered Person/ApplicantLetter of confirmation issued to

Registered Person/Applicant

NO

Inform Registration Manager,

Communications Manager and

relevant stakeholders.

Update RQIA’s website.

NO

See DMP Procedure

(Document 5)

See DMP Procedure

(Document 5)

YES

Inform stakeholders Registration

Manager, Communications

Manager and update RQIA’s

website

Inform stakeholders Registration

Manager, Communications Manager

and update RQIA’s website

Prepare application and seek

legal advice is required

RQIA’s decision

confirmed?

Inform stakeholders, Registration

Manager, Communications Manager

and update RQIA’s website

YES

YES

YES

NO

NODid the Lay Magistrate

issue an order?

Urgent ProceduresChart 8

Decision made to apply to a Lay

Magistrate for an order under the

Urgent Procedure

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

EDM Meeting

(see chart 1)

RQIA’s decision

confirmed?

Serve order to the

Registered Person/s

(takes effect immediately)

Appeal submitted to

Care Tribunal?

Inform all relevant stakeholders

and RQIA’s Board of RQIA’s

intention to apply for an order

Submit application to Lay

Magistrates

See DMP Procedures

(Document 6)

See DMP Procedures

(Document 6)

NO